Travel reservations: Push for offshore care

Getting a passport in preparation for surgery isn't on the minds of most patients. But the medical tourism industry is betting that it will be soon, as a small but growing group of companies work to create a medical travel system that is so well-oiled, they brag that scheduling surgery abroad will be easier than booking a vacation.

Firms are offering perks from full-service bookings that include recuperation time at four- and five-star hotels, money-back guarantees and even liability insurance -- like the kind someone would buy for a rental car -- to lessen the trepidation for patients considering overseas care.

The companies aren't just waiting for that comfort level to rise, either. They are courting large employers and health plans by promising to find the best foreign hospitals they claim rival U.S. facilities in quality measures, all while saving them up to 80% in health care costs so they will offer employees and members incentives for seeking care abroad.

And the medical travel companies themselves are being courted by countries and overseas hospitals eager to take American patients. For example, the director of medical services for the Singapore Tourism Board said 555,000 tourists had received medical treatment in that country last year. Singapore would like to bring that number to 1 million per year by 2012.

Wockhardt Hospitals in India has posted a series of videos on YouTube targeted to specific procedures and specific countries patients might be coming from. Hospitals also are organizing tours for medical travel companies, hoping to be included in their networks.

The companies say they have plenty of employers, particularly the self-insured, who are all ears in listening to their pitches. But some analysts say that despite the touted cost savings, those employers are being cautious about medical travel. Some seem interested, but few have fully embraced the concept so far.

"I continue to think that the only thing missing is the one good success story," said David Franzinni, principal of Mercer, a global human resource and financial consulting firm working on its own medical travel initiative.

For most medical travel professionals, individual clients come their way via word of mouth or by patients researching medical travel on the Internet. The business has been good, they say. Some report double the business from a year ago.

The industry has grown large enough to warrant forming its own trade group. The Medical Tourism Assn. will have its first meeting at the Second Annual International Medical Tourism Conference in December.

But while the focus has been on the uninsured, or those seeking procedures not covered by insurance, the real potential for growth, in the eyes of medical travel companies, is with self-insured employers and health plans that can offer big incentives to patients.

GlobalChoice Healthcare, based in Albuquerque, N.M., started two years ago as a medical travel company focused on the uninsured. But Matthew Fontana, MD, the company's vice president of client services, said the firm has evolved into a benefit provider that sells "global health care" packages to self-insured employers.

The company has formed a network of hospitals, both foreign and domestic, that it contracts with to steer members to whoever has the best rates on procedures. Employers contract with GlobalChoice on a per-employee, per-month basis so that if a patient is in need of a medical procedure and is willing and able to travel, GlobalChoice handles the arrangements.

Many medical travel firms will arrange every aspect of the trip for their clients, including airfare, hotel reservations, transfer of records and postoperative meetings between the surgeon and the stateside primary care physician. Some go so far as to provide a point person to meet the patient at the airport and act as the patient's agent, translator and advocate for the duration of the trip.

While many refer to the industry as "medical tourism," most in the business downplay the touristy aspects of the trip. They prefer the term medical travel. But they tout the resort-like atmospheres at the hotels where patients recover.

Wouter Hoeberechts, CEO of Concord, Calif.-based WorldMedAssist, started in the industry 18 months ago dealing mostly with the uninsured. Although business has been good -- the company recently arranged for the first known liver transplant on an American done in India -- and it plans to continue working with individuals, he said the company is now in the process of securing contracts with self-insured employers. He hopes an employer stamp of approval will make more patients comfortable with the idea, he said.

Insurers also are starting to show an interest in exporting patients. BlueCross BlueShield of South Carolina was among the first to get involved in the industry. Earlier this year, it created Companion Global Healthcare, a wholly owned subsidiary that helps arrange travel and care for patients going to Thailand's Bumrungrad International hospital.

David Boucher, assistant vice president for health care services for both the South Carolina Blues and Companion Global, said that as an independent licensee of the BlueCross BlueShield Assn., it cannot contract with hospitals outside the state. But as an independent firm, Companion Global can negotiate prices with international hospitals for procedures patients pay for in cash. It plans to have five or six more hospitals in its "international network" in three months.

Companion Global is offering its services to Blues members in need of procedures their insurance will not cover. It also is negotiating with self-insured employers that have plans administered by the Blues to develop other plans that include incentives for medical travel. Boucher expects some of those contracts to be in place in 2008. The company is also marketing its services to the uninsured.

While employers have shown interest in sending employees abroad, one reason they have been slow to respond is the lack of regulation in the medical travel industry. It's completely unregulated and an easy business to get into, Hoeberechts said.

In many cases, the closest thing to regulation is certification from the Joint Commission International, a branch of the Joint Commission, which certifies U.S. hospitals.

"That seems to be the buzz term," Patrick Marsek said of JCI accreditation. Marsek, managing director of Vernon Hills, Ill.-based MedRetreat, said that although his company does contract with some of the 136 JCI-accredited hospitals abroad, it doesn't exclude those not accredited. In fact, he said, sometimes JCI accreditation is a negative.

JCI-accredited hospitals charge 30% to 35% more than nonaccredited hospitals, he said. "You want to make them look like American hospitals, and it costs to do that. The majority of people paying out of pocket want the best value, and that would be with the non-JCI market," he added.

Marsek and his staff visit each hospital, meet with staff, review mortality and infection rate data, and assess the hospital's cleanliness. "We make the determination based on would we feel comfortable going to the hospital ourselves," he said.

Hoeberechts calls the higher cost of JCI-accredited hospitals insignificant. And the "objective stamp of approval" goes a long way to establish a level of quality that most potential clients can identify with and trust.

"Quality and safety do have a cost, and accreditation is basically a risk-reduction activity," said Karen Timmons, president and CEO of JCI.

At its Annual Meeting in June, the American Medical Association House of Delegates considered a resolution that would require medical travel companies to disclose to clients possible risks associated with traveling abroad. The resolution also required a method compliant with the Health Insurance Portability and Accountability Act for exchanging records, and it sought the creation of CPT codes specific to postop care for procedures done abroad. The resolution also called for the AMA to work with the JCI and other organizations to assess the quality of the offshore hospitals. A separate resolution asked that the AMA push for legislation to prevent insurers from offering incentives for members to seek care abroad.

The resolutions were referred back to the Board of Trustees for consideration, and a report by the Council on Medical Services is expected at the 2008 Annual Meeting.

Some in the medical travel industry say closer scrutiny actually might be good for their business. "We hope for more regulation in this industry. It's needed," said Hoeberechts, who supports the proposed AMA resolutions. He said his firm is talking with American physicians trying to educate them on the industry in hopes of getting not only support from the physician community but also referrals and access to follow-up care.

Physicians are sympathetic to patients who can't afford needed treatments, he said. So if the industry can prove to physicians that it's safe to go abroad, he hopes more will suggest the idea to patients, as some already have. His first client was referred by an American doctor, he said.

Various reports estimate there are 150,000 to 500,000 health care-related visits annually by Americans to other countries. But some analysts say a boost to those numbers, courtesy of insured patients, might come anywhere from soon to not at all.

Franzinni said it will be hard for the industry to expand much beyond the self-insured employer market. There would be more regulatory issues for insurers. And from a business standpoint, a lot more people would need to be willing and able to do this before insurers could offer incentives significant enough to get members on board.

Health care attorney Scott Edelstein, from the Washington, D.C., offices of Squire, Sanders & Dempsey, has seen evidence of the insurance industry becoming the leaders in the movement. The regulatory issues wouldn't be a big issue, he said, and the potential cost savings would be too much for most insurers to ignore.

Insurers realize the U.S. health care system is dysfunctional, he said. "Medical tourism may ultimately be the thing to trigger a change."

Josh Jacobs, MD, a Chicago orthopedic surgeon and a spokesman for the American Academy of Orthopaedic Surgeons, said he doesn't yet consider offshore doctors a competitive threat, but doctors need to be open to talking to patients about possible risks of traveling abroad.

Even though Dr. Jacobs personally hasn't dealt with any patients considering such travel, he has developed a checklist of safety issues doctors should discuss with patients considering this option. His list includes the adequacy of ancillary staff and services, the credentials of support staff, the quality of blood products and the hospital's device regulation.

Richard Wade, executive vice president for the American Hospital Assn., agreed that the industry will remain a niche market, since not everyone will be willing to travel, not even to save a few thousand dollars. "All of this is an indicator of how people's notions of health care in some respects is more global than it used to be," Wade said. "But I don't think you'll have great numbers of people going to India for care. It's not quite in our culture."