Medical Travel Today is a publication of CPR Strategic Marketing Communications, a firm based near New York City that specializes in medical, technology and medical tourism companies, with an international clientele. CPR, its partners and clients are at the nexus of where medical travel is today, and where it will be tomorrow.

Publisher: Laura Carabello

CONTENTS

From the Editor: This week in Medical Travel Today, by Jeff Schult, editor and author of Beauty from Afar...
News in Review: News and briefs and new links from around the web and around the world...
Spotlight: The Ethics of Medical Tourism.

Medical Tourism Association: Advisory Board announced
Issues and Answers: Dr. Michael Horowitz on why costs of care abroad can be so low, relatively.
Press Releases
Privacy Policy

PRESS RELEASES

MedPharma Partners and MedTripInfo.com Release White Paper on Medical Tourism
PRWeb.com
White paper provides medical tourism predictions and implications for participants in the US health care system, including health plans, employers, health care providers, pharmaceutical companies and medical device companies.

Medical tourism saves you thousands, but do your research
TreatmentAbroad.net
The rapid growth of medical tourism has allowed Britons to save thousands of pounds on medical procedures.

Medical Tourism. Panama and Australia.
PressMediaWire.com
Medical Tourism in Panama will have a “call center” in Sydney, Australia dedicated to the Australia and New Zealand region.

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THIS WEEK IN MEDICAL TRAVEL TODAY (Vol. 1, Issue 3):

By Jeff Schult, Editor
and author of Beauty from Afar

Our top story this week actually had its genesis back in July when, as part of my more or less daily scan of the Internet in search of the latest about medical tourism, I ran across an item that seemed a bit out of the ordinary. A prominent United States insurer, Harvard Pilgrim Health Care, had, without much fanfare, held a symposium on the ethics of medical tourism. I was intrigued and contacted Dr. James E. Sabin, MD, director of the company's ethics program and set in motion a process that led to Harvard Pilgrim agreeing to share with us the report of its Ethics Advisory Group. Among the group's conclusions, just to whet appetites:

"On the assumption that a host of important practical problems could be solved, the EAG felt that offering high quality/low cost treatment abroad could provide a win/win opportunity. If incentives were designed properly members, purchasers and HPHC could all save money while providing high quality care."

Though the ethics panel does not set policy for Harvard Pilgrim, we thought the report would be of interest to any business entity with an interest in what part medical travel will play in the future of the U.S. healtcare system, and are proud to offer this issue.

We are also proud to welcome back Michael Horowitz, MD, MBA, with Part 2 of a three-part article that examines the economics of outsourcing medical care.

Jeff Schult, Editor
Mr. Schult can be reached at editor@medicaltraveltoday.com.

SPOTLIGHT:
The Ethics of Medical Tourism
A U.S. Insurer Takes a Thoughtful Approach

Special to Medical Travel Today
Introduction and Editing by Jeff Schult
©2007 Medical Travel Today

It is, of course, big news in the medical tourism industry when a major media source steps up and examines what's going on, identifies the trend, moves the story forward or even just shares the experience of patients with readers or viewers.

But Medical Travel Today is just as fascinated - or perhaps more so - when we hear about the dialogue that's going on between professionals at high levels in managed care in the United States.

In mid July, the Harvard Pilgrim Health Care Ethics Advisory Group (EAG), in response to questions about medical tourism that percolated through the health insurance company, met to discuss medical travel from the standpoint of the ethics of the insurer. The EAG is made up of Harvard Pilgrim staff, employers, physicians from Harvard Pilgrim's network and members. The group provides advice to Harvard Pilgrim managers and leaders on values-related aspects of issues submitted to it for consultation.

While hospitals, of course, have formal ethics panels, it is less common, even rare, for insurance companies to have such bodies. We thank Harvard Pilgrim and James E. Sabin, MD, director of the company's ethics program, for sharing with us the ethics panel's report.

The report's recommendations are strictly advisory and neither reflect current policy at Harvard Pilgrim nor predict the future. But they provide a unique glimpse into the kinds of issues managed care firms will wrestle with as medical tourism becomes a possible or even likely option.

After describing medical tourism generally, from news reports, the report delves directly into the ethical issues. Among the conclusions:

"On the assumption that a host of important practical problems could be solved, the EAG felt that offering high quality/low cost treatment abroad could provide a win/win opportunity. If incentives were designed properly members, purchasers and HPHC could all save money while providing high quality care."

The following is excerpted from the report:

Questions for the Ethics Advisory Group

HPHC is just beginning to receive requests for treatment abroad. In the last 16 months there have been four appeals re out of country treatment - (a) to Belgium for a hip resurfacing surgical procedure that was not (at the time) FDA approved, (b) to Germany for a laparoscopic procedure for abdominal adhesions that was not FDA approved, (c) to the Philippines for a chemotherapy in a breast cancer trial for an agent that was not FDA approved or yet in trial in the U.S. and (d) to Austria for an experimental treatment for glioblastoma multiforme (a malignant brain tumor) that was not FDA approved. Since FDA approval is typically a necessary condition for coverage all four appeals were denied.

As (a) the standard of care at overseas sites continues to improve, (b) U.S. cost escalation continues its inexorable trend, (c) marketing to potential medical tourists becomes more sophisticated and aggressive and (d) media and the web report on positive experiences with overseas treatment it is (e) inevitable that questions about medical tourism will arise with more frequency for HPHC. On July 18^th the EAG was asked to offer consultation to HPHC leadership as it develops principles for future coverage policy. Questions included:

For enrollees with PPO products that cover out of network services and do not limit their care to a contracted network, what values considerations are relevant to defining the geographical boundaries of the PPO coverage? From the perspective of values what is the rationale for saying "yes" or "no" to overseas treatment?

HMO enrollees receive their care from a defined network of providers. Treatment outside of the network is ordinarily approved only if it is not available within the HMO network. What, if anything, should HPHC cover as part of its benefit structure when HMO members request outside-of-U.S. services? What values considerations are relevant to answering this question?

How should HPHC think about the impact of medical tourism on the host country? Suppose it appears that medical tourism is siphoning human and financial capital away from the host country system or organs for transplantation away from host country citizens on transplant waiting lists? Suppose there is suspicion that donors are being paid to provide organs?

It is inevitable that some HPHC members will go abroad for treatment in circumstances in which HPHC approval has been requested and denied. What values are relevant to deciding who is responsible for the cost of follow up treatment if complications occur?

Relevant precedents

On September 21, 2000 the EAG discussed "What Level of Quality is ‘Appropriate' for a Member's Care?" The case focused on a request from an HMO member for prostate cancer treatment at Johns Hopkins, based on his contention that an "appropriate" level of quality was not available within the HMO network. The report includes this paragraph:

With regard to the question of whether the relevant elements of quality have been demonstrated in an adequately objective manner the EAG made a distinction. The EAG believed that the nerve sparing technique itself had been demonstrated to be superior to non nerve sparing surgery. It questioned, however, whether a meaningful difference between nerve sparing surgery by Dr. Walsh at Johns Hopkins and nerve sparing surgery available within the HPHC network had been objectively demonstrated. There was no doubt that Dr. Walsh is highly competent and that Mr. A strongly preferred having the surgery at Johns Hopkins with Dr. Walsh. The EAG felt, however, that it is important to distinguish between claims of superiority and objectively demonstrated superiority.

In a meeting devoted to "Developing a Framework of Values for Determining when Interventions are ‘Experimental' and ‘Unproven'" (November 9, 2005) the EAG reaffirmed its commitment to a high standard of evidence for coverage decisions:

The EAG emphasized that making decisions about coverage for new technologies requires a prior decision about the standards for "good enough evidence"... the EAG again strongly endorsed the high standard put forward in the Benefit Handbook[1] as consistent with the mission of "improv[ing] the health of the people we serve" and the historical medical ethics teaching - "first, do no harm."

The EAG had not deliberated about out-of-the-US treatment heretofore - July 18^th involved new territory!

EAG DISCUSSION/RECOMMENDATIONS

At the outset of the discussion the EAG put the topic of medical tourism into the broad context of globalization. US healthcare occurs in a market environment and markets extend beyond national boundaries. We should expect overseas providers to compete for a share of the US health care market and US consumers to "shop" for health services abroad as well as at home. Likewise, we should expect to see outsourcing to occur in health care as it does in other industries. Already some radiologists in the HPHC network are using "nighthawk" programs in India in which US trained radiologists read scans taken at night in US facilities. And, HPHC's Perot partner has moved selected backroom functions to India. These globalizing trends will accelerate, probably quite rapidly.

The EAG recognized the many practical problems associated with treatment outside of the United States. Before HPHC considered covering overseas treatment it would need to be able to assess quality of care. The Joint Commission International certification program provides a start, and it will not be long before entrepreneurial enterprises begin to offer new quality monitoring reports. If HPHC sponsored treatment abroad it would have to ensure continuity of care for when patients returned to the US. Legal issues would have to be addressed, such as what sort of liability protections patients would have if something went wrong at a foreign hospital and whether HPHC would have any special liability in such circumstances. But the EAG conducted its deliberations on the assumption that these practical problems could be solved.

The EAG reached a strong consensus that if (a) high quality care at a favorable price was available overseas and (b) issues of continuity of care, legal liabilities, etc could be successfully addressed, then (c) covering overseas care would support many important HPHC values:

Insofar as high quality care at a lower cost was available overseas covering it would advance the HPHC mission to "improve the health of the people we serve."
As HPHC serves more large national accounts through its alliance with United Health it will deal increasingly with companies that have employees outside of the US and require solutions for these employees' needs. Skill in addressing overseas treatment would allow HPHC to serve its large corporate customers better.
Self-insured companies are likely to see high quality/low cost overseas treatment for selected conditions as a benefit for themselves and their employees. In this way too, skill in addressing overseas treatment would allow HPHC to serve this segment of its corporate customers better.
In the context of high deductible health insurance the EAG imagined that in the future health plans might wave the deductible for patients who had selected procedures done overseas. This would benefit the patients and the health plan.
One EAG participant commented that "the U.S. health system is clearly broken and costs are out of control...from a competitive perspective, endorsing overseas treatment would send a strong message to U.S. providers that costs must be controlled better!" Another participant commented that covering treatment abroad is a form of "outsourcing cost containment, an area managed care has largely given up on in the US!"

The EAG briefly discussed the issue of members who want to go abroad for treatment that is not FDA approved or otherwise available within the United States. The group felt that its previous recommendations with regard to a framework of values for coverage of new technologies apply to this area as well. The same standards for judging whether to cover treatment in the U.S. (FDA approval, etc) should be applied to requests for treatment overseas. Requests are likely to be more common in the future as it is easier for drug companies to do initial Phase I studies in developing countries than in the US.

With regard to the question of who should be financially responsible if members choose to go abroad for treatments for which HPHC approval has been denied the group was divided. Some felt that "health insurance covers injuries from doing dumb things like bungee jumping, so why shouldn't it cover injuries from other dumb choices, like going abroad for unapproved treatment?" Others felt that if members (a) know that their insurer does not see the requested treatment as appropriate for coverage and (b) choose to go ahead on their own then (c) they should be financially responsible for the full treatment, including (d) treatment of complications arising from the unapproved treatment.

The EAG spent the final half hour of the meeting discussing the impact of medical tourism on the host country. It recognized the possibility that high quality/good value treatment for Americans could have negative effects on the host country:

There could be an internal "brain drain" in the host country if the most qualified physicians gravitated towards facilities serving foreigners.
In poor countries persons living in dire poverty may sell organs for transplant in hope of providing better for their families. The EAG debated whether individuals should be allowed to make "informed choices" about sale of organs. The consensus of the group was that even if the host country accepted voluntary sale of body parts a US health plan should govern its practices by its own values and the values reflected in the US prohibition on selling body parts.
One participant reported having been at a presentation describing allegations that in several countries prisoners were used as a source of organs and that involuntary tissue typing was done on admission to the prison as a way of "inventorying" available organs.

The EAG recognized that HPHC cannot solve the problems of poverty in countries that host medical tourism or ensure optimal distribution of the host country's medical resources. But the group felt that the last five words of the HPHC mission - "to improve the health of the people we serve and the health of society (emphasis added)" -- should be interpreted to refer to the host country's society as well as US society. Especially for extreme examples like sale of body parts or "harvesting" transplant organs from prisoners HPHC should not serve its members by means that produce significant harms to the host country.

The EAG emphasized the importance of transparency in any developments with regard to medical tourism. Endorsing transparency means that if getting high quality treatment at a lower price is the rationale for offering coverage that should be made explicit to stakeholders. Similarly, transparency means that issues like the potential impact of medical tourism on the host country should be addressed openly and proactively. HPHC aspires to being a thought leader with regard to health care policy, and medical tourism offers an opportunity to speak out in an educational manner.

Summary

1. On the assumption that a host of important practical problems could be solved, the EAG felt that offering high quality/low cost treatment abroad could provide a win/win opportunity. If incentives were designed properly members, purchasers and HPHC could all save money while providing high quality care.

2. The EAG felt that the same values framework HPHC uses for deciding about coverage for treatments in the US (FDA approval, evidence base, etc) should be applied to requests for treatments abroad.

3. The issue of how medical tourism impacts host countries is complex, but the EAG felt that these impacts should be considered if and when HPHC considers coverage of overseas treatments. The EAG felt that fundamental HPHC and U.S. values - such as the view that body parts should not be sold (or, in the case of prisoners, taken) - should be adhered to, even if the host country accepts these practices.

4. The EAG strongly supported the active way in which (the referring manager) and his colleagues were addressing medical tourism - beginning to plan for the area in a proactive manner, not simply responding to trends as they emerged. The group thanked (the manager) and his colleagues for allowing it to undertake this anticipatory ethical analysis of the area before any problems hit the fan!

Editor's Note: Harvard Pilgrim's website is: www.harvardpilgrim.org. Dr. James Sabin has launched a blog on the ethics of healthcare organizations at: http://healthcareorganizationalethics.blogspot.com.

[1] The section on exclusions in the Harvard Pilgrim Schedule of Benefits states "Drugs, devices, treatments or procedures which are Experimental or Unproven [are excluded from coverage]." Here is how the HPHC Benefit Handbook defines the key terms:

A service, procedure, device or drug will be deemed Experimental or Unproven by HPHC under this Member Agreement for use in the diagnosis or treatment of a particular medical condition if any of the following is true:

a. The service, device or drug is not recognized in accordance with generally accepted medical standards as being safe and effective for the use in the evaluation or treatment of the condition in question. In determining whether a service has been recognized as safe or effective in accordance with generally accepted medical standards, primary reliance will be placed upon data from published reports in authoritative medical or scientific publications that are subject to peer review by qualified medical or scientific experts prior to publication. In the absence of any such reports, it will generally be determined that a service, procedure, device or drug is not safe and effective for the use in question.

b. In the case of a drug, the drug has not been approved by the United States Food and Drug Administration (FDA) (This does not include off-label use of FDA approved drugs).

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Medical Tourism Association Advisory Board Announced

©2007 Medical Travel Today

The Medical Tourism Association has announced its Advisory Board, which draws upon the expertise of thought leaders worldwide. The MTA is a not-for-profit organization comprised of top international hospitals and clinics, leading medical tourism companies, employers and benefits payers, as well as key influencers worldwide.

Members are:

ROBERT K. CRONE, MD, President & CEO of Harvard Medical International; Boston, Mass.
JOHN F. P. BRIDGES, PhD, Assistant Professor at Johns Hopkins Bloomberg School of Public Health; Baltimore, Maryland
PRADEEP THUKRAL, Head of International Marketing at Wockhardt Hospitals Group; Mumbai, India
THOMAS JOHNSRUD, Senior Consultant, N.A., Parkway Hospital; Singapore
BRAD COOK, International Benefits Director at Hospital Biblica Clinica; Costa Rica
KAMALJEET SINGH GILL, GM, International Business Development Unit of National University Hospital; Singapore
JONATHAN EDELHEIT, President, Medical Tourism Association, Inc.; Palm Beach, Florida
RENEE-MARIE STEPHANO, Esq., General Counsel for Medical Tourism Association and Editor of The Medical Tourism Magazine
STEPHEN M. WEINER, Esq., Chairman of the Health Law Practice of Mintz, Levin, Cohn, Ferris, Glovsky & Popeo, P.C.; Boston, Mass.
SCOTT A. EDLESTEIN, Esq., of Counsel at Squire, Sanders & Dempsey, LLP; Washington D.C.
DANIEL BONK, Executive VP ~ Central Region, Aurora Healthcare; Wisconsin
FREDERIC J. ENTIN, Esq., Partner at Foley & Lardner, LLP; Chicago, Ill.
MARY ANN KEOUGH, Professor at Eastern Washington University; Washington State
DALE C. VAN DEMARK, Esq., Member of Epstein, Becker & Green, PC; Washington, D.C.
KEVIN RYAN, Esq., Member of Epstein, Becker & Green, PC; Washington D.C.
LAURA CARABELLO, Principal of CPR Communications, Publisher of Medical Travel Today Newsletter; New York
RUBEN TORAL, Proprietor of MedNet Asia, Ltd.; Bangkok, Thailand
DAVID C. KIBBE, MD, MBA, Principal of The Kibbe Group LLC; North Carolina

For more information about the association, visit www.medicaltravelauthority.com or write to: info@medicaltravelauthority.com

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ISSUES AND ANSWERS:

Why is Offshore Medical Care so Inexpensive?

The Macroeconomic Basis of Medical Tourism (Part 2 of 3)

Editor's Note: Dr. Michael Horowitz has been researching medical tourism and international medical travel since 2005 in collaboration with Professor Jeffrey Rosensweig, Director of the Global Perspectives Program, Goizueta Business School, Emory University. He is the author of several articles on medical tourism and has given professional presentations on this subject.

A graduate of the University of Miami School of Medicine, Dr. Horowitz practiced Cardiothoracic Surgery for more than 15 years. He has an MBA from Goizueta Business School of Emory University.

Dr. Horowitz is currently forming a consultation practice devoted to researching, analyzing and providing valuable information and critical insights about medical tourism and international medical travel.

In the first part of this article we saw that three major factors make it possible for patients from industrialized nations to get health services in developing nations at low cost: Macroeconomics, Management issues, and Medicolegal considerations.

As we already know, the primary reason for lower costs in medical tourism is the disparity in the level of economic development between a patient’s country of origin and the destination where care is provided. Although there are of a number of ways to evaluate a country’s level of economic development, in this situation we need a measurement that considers the fact that a patient lives, works and saves money in one country but will have to pay for services in another.

Even when providers quote prices for services in U.S. Dollars, they are actually determining these charges in their own currency. The patient may give payment to a medical tourism agent in U.S. Dollars who, in turn, deposits the money into a U.S. bank account.But eventually, providers will want to repatriate all or some of this money into their own country – where they live, work, save, and pay bills.

The economic measure that is most suitable for our purpose is the destination country’s per capita gross domestic product (GDP) converted to U.S. Dollars using market exchange rates (MER). A country’s per capita GDP refers to the market value of all final goods and services produced, per person, in a certain period of time (say, a year).

MER refers to the prices paid for one currency, in terms of the other currency, in the foreign exchange market. Have you ever wondered how they determine exchange rates at the kiosks in airports? Unknown to many people is that there is a currency market, the FOREX market, where central banks, large commercial banks, large multinational companies, brokers and speculators buy and sell various currencies – just like the stock market.

This is a huge market, open electronically 24/7, with global transactions in excess of US$ 2 trillion daily (Really -- $2 trillion per day). So every day Baht, Dollars, Euros, Pesos, Pounds, Rupees and Yen are bought and sold – the prices that participants are willing to pay or accept in one currency in order to buy or sell a different currency determines market exchange rates.

So how does all this relate to the price of medical services in a faraway country? The per capita GDP, based on MER, is a marker for the average wage levels in these countries. In developing countries with weak currencies relative wages may be remarkably low. Therefore, patients from the Unites States (and other industrialized nations) dramatically enhance their financial position when they convert their strong Dollars into the currency of the destination country.

An example of the disparity in the level of economic development is illustrative: In 2006, the per capita GDP for the United States was US$ 44,244. For that same year, India’s per capita GDP, converted to US$ using MER, was US$ 840. Recalling that this is a proxy for relative wages, let’s consider a patient who has to pay a certain amount of money for one hour of nursing care in Chicago. This patient could, alternatively, convert this money to Indian Rupees and purchase over 50 hours of nursing care in Chennai.

In Part 3 we will continue to explore the ways that economic issues determine costs in the global health care marketplace.

Dr. Horowitz can be reached at michael_horowitz@mac.com

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Editor's Note: This newsletter is for informational purposes only and should not be construed as medical advice.

NEWS IN REVIEW:

Canada a mecca for medical tourism?
Toronto Star
Out-of-country patients are a `potentially massive new industry,' says CMA head, if wait times are cut

Long-distance surgery is a snip
Times Online
Medical tourism can save you thousands of pounds, but do your research first, says Mark Bridge

Industries promote medical tourism
Taipei Times
A new business alliance between a popular hotel, a travel agency and a medical association announced a program yesterday to promote medical tourism in Taiwan. ...

Two KL hospitals woo ‘tourists’
NST Online
BATU PAHAT: The Health Ministry is pursuing international accreditation for two Kuala Lumpur hospitals to boost medical tourism.

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