THIS WEEK IN MEDICAL TRAVEL TODAY
By Laura Carabello, Publisher

Please join me in wishing our colleague Jeff Schult every success as he moves to Massachusetts and delves into some research projects. We anticipate that Jeff will contribute to this newsletter from time to time and stay connected to our growing family of medical tourism professionals.

With my roots firmly planted in the world of newspaper reporting and editing, it gives me great pleasure to introduce this issue which includes the perspectives from some of this industry’s emerging thought leaders.

For those who are familiar with the work of David Kibbe, M.D. and his position of influence in the health care IT community as well as the AAFP, you know his passion for widespread adoption of CCR-compliant Electronic Health Records (EHRs) in the United States. During a recent interview, we’ve also learned about his equally passionate views on the worldwide implementation of this technology – what it will take for the international community of health care providers to make interoperable EHRs a reality and the likelihood of success.

And if the name Milica Bookman is not on your radar screen, it should be. Professor Bookman is the co-author of "Medical Tourism in Developing Countries," a groundbreaking study that has become an important reference in the understanding of healthcare globalization. Her original article points to some of the economic realities of medical tourism and helps us to better understand and forecast what it will take to be a winner in this global market.

We’ve also heard from our friends down under in New Zealand. You’ll learn from Edward Watson, M.D., CEO of Medtral New Zealand, the value of hospital accreditation and how he and his colleagues are meeting the challenges. While I’ve never visited New Zealand, my friends report that it is a fabulous spot for tourists – and now we expect to hear more about its value as a medical tourist destination. Stay tuned…

Finally, if you have not yet made plans to attend the International Medical Tourism Conference, December 3-5, 2007 at Consumer Health World, please don’t delay. The programming and opportunities to network are unparalleled in the industry

Laura Carabello, Publisher
Ms. Carabello editor@medicaltraveltoday.com or lcarabello@cpronline.com

The world is closer to the grail of universal Electronic Health Records (EHRs) than most people think, and continued progress will help to make medical travel safer, according to one of the leading innovators in medical informatics, David C. Kibbe, M.D., MBA.

Dr. Kibbe is a senior adviser to the Center for Health Information Technology (HIT) of the American Academy of Family Physicians (AAFP) and a principal of The Kibbe Group LLC in Pittsboro, North Carolina. He is co-developer of the ASTM Continuity of Care Record (CCR).

David Kibbe, M.D., MBA

“The ‘Pie in the Sky’ is that, ultimately, most providers and institutions would have EHR infrastructure and a paperless environment,” he said in an interview with Medical Travel Today. “We’re seeing it occur in the United States rather rapidly, under adverse circumstances. In Minnesota, 67 percent of institutions are now using EHR, a statistic that might surprise a lot of people. The top-flight medical destinations pretty much all have EHR.”

Going forward, Kibbe said, medical records technology must provide for:

“… Secure, private, and accurate aggregation and transport of all relevant personal health information, using tested international standards and methods, to assure that patients' experience continuity of information flow between their medical home and medical tourism providers and institutions, and are assured that nothing important about their medical history gets left behind.”

He expects EHR and CCR standards to evolve in several ways, on different fronts. “Global destination parties” such as Microsoft (the recently opened-for-business Healthvault.com) and Google (still in demo mode) have already launched online health record initiatives. Another likelihood is that some group with international credibility will step in and provide guidance and standards; and yet a third probability is that a business association, an industry consortium or even an individual business with proprietary but advanced technology will take the lead.

Dr. Kibbe views universal EHR/CCR as inevitable, given the likely improvement in quality of care, reduction of errors and cost savings.

“There is too much of an incentive to succeed,” he said. Problems between countries such as language will be resolved by electronic translation and/or settling on English as the common language for EHRs, he said.

Besides his work in EHRs/CCRs, Dr. Kibbe is also an experienced clinician who practiced medicine in private and academic settings for more than 15 years, while also teaching informatics at the School of Public Health, University of North Carolina at Chapel Hill, and founded two medical software companies. In 2005, he was voted one of the 50 Most Powerful Physician Executives in Healthcare by readers of the magazine Modern Physician.

From 2002 until 2006, Dr. Kibbe was the founding director of the Center for Health Information Technology for the AAFP, the membership organization that represents over 95,000 U.S. family doctors. The Center is now the locus of the AAFP’s technical expertise, advocacy, research and member services associated with HIT, and a leading national resource on information and communications technology for physicians.

During Dr. Kibbe’s tenure as Director of the Center for HIT, AAFP physician member adoption and use of EHRs more than tripled, from 12 percent to over 40 percent.

Professor Milica Z. Bookman is the co-author of "Medical Tourism in Developing Countries," a groundbreaking study that "explores a subject that has been missed by researchers and policy makers but also makes a unique contribution to our understanding of globalization," according to Henri J. Barkey, Department Chair and Cohen Professor of International Relations at Lehigh University. Bookman is professor of economics at St. Joseph's University in Philadelphia and was educated at Brown University, the London School of Economics, and Temple University. She is the author of ten books on economics as well as numerous articles.

The globalization of healthcare, which includes medical tourism (MT), has become a reality. The health care industry, just like manufacturing and software, has become global, with changes in the location and nature of delivery and consumption of healthcare services. This process entails new challenges and opportunities for both destination and sender countries. MT suppliers as well as western payors and employers must all tread with caution as they position themselves in the still wide-open industry. In responding to changing demand and supply conditions, healthcare industries in both destination and sending countries should learn from recent economic history.

Specifically, during the 20th century, production of goods and services moved from one location to another in response to changes in production and transportation costs (for example, manufactured goods such as hand calculators were first made in the United States, then in Japan, then in Malaysia and most recently in China). As the production of some goods and services moved away, economies had to adapt to new conditions by re-evaluating, re-structuring and re-equilibrating in order to diversify into the production of other goods and services more suited to their conditions.

A similar shift in the spatial location of medical service supply has occurred. Indeed, several decades ago, American hospitals such as the Mayo Clinic drew patients from across the world. While the U.S. remains attractive to international patients for specialized procedures, the volume growth in foreign demand appears to be shifting towards lower cost providers across the world. In addition, domestic consumers in western countries are finding it cost effective to travel to developing countries.

Where does that leave sites such as the Mayo Clinic? While it still draws international patients for sophisticated and complicated medical procedures, it has had to reorient its services to respond to the changing overall composition of its patients (for example, along with many hospitals across the U.S., the Mayo Clinic now provides luxury healthcare for Americans, also known as concierge, executive or boutique services). In the meantime, destination countries such as India, Thailand, Singapore and Costa Rica have emerged, offering their healthcare facilities to international patients and stimulating a bandwagon effect across the developing world.

Ironically, the economic reality of shifting production locations means that countries currently promoting medical tourism are likely to lose their advantage in the production of medical tourism as their own economies develop and their own production costs increase. And develop they will — that is the consequence of a successful medical tourism industry. Then, having lost their advantage and no longer being able to provide low cost services, the supply locus of medical tourism is likely to move elsewhere.

In other words, comparative advantage in the provision of medical care is not set in stone. In fact, given the pace of 21st century globalization, it is set in sand. Today, changes occur faster than before as geographical distances have effectively shrunk, communication is instantaneous and information is virtually perfect. Comparative advantages don’t last as long as they previously did. Product cycles are shorter and spatial location of production changes faster than it ever did in history.

Destination countries must couple this fact with the nature of demand for medical tourism services. Specifically, while the medical tourism industry as a whole faces a high price elasticity of demand, and as a whole, the industry faces high income elasticity of demand, any single country (or provider within a country) faces fierce competition and produces services that are ultimately substitutable. We are moving beyond diaspora-induced medical tourism, in which patients are drawn to their former home country for healthcare because it is familiar. In the mass medical tourism market that is on the cusp of taking off in the west, price considerations will be crucial in a market full of substitutes.

Together, the realities of comparative advantage and demand elasticity in medical tourism have huge economic implications for destination countries. They imply that these countries are fighting against time in an increasingly competitive industry. While the medical tourism industry worldwide is growing, the window of opportunity for each destination country will start to shrink rapidly. Therefore, while medical tourism is an infant industry in which players are bracing themselves for a blooming adulthood, it is not too early to look into the future and prepare for its maturation and stabilization. While destination country authorities seek to maximize the possibilities offered by medical tourism and to respond to the burgeoning demand from both the west as well as their neighbors, they must also plan for the replacement economy that will inevitably be needed one day. No one can assume that healthcare market conditions will be the same in a generation as they are today. In fact, one must assume they won’t be.

The mass medical tourism industry, while now new and innovative, will follow the same economic rules as other more mundane industries that also struggled to adapt to global economic shifts. Price advantage is fleeting and for this reason price should not be the sole basis for comparative advantage. To remain a player in the increasingly competitive medical tourism world, destination countries will have to offer more than just a price advantage. Niches based on state-of-the-art technology, quality of care, and personalized service will become more important although, alas, harder and harder to establish. For all these reasons, it is not too early to begin thinking several chess moves ahead.

Professor Milica Bookman can be reached at: mbookman@sju.edu

Medical Travel: What happens when things go wrong?
Edward Watson, M.D., CEO Medtral New Zealand

Dr. Watson is the founder and CEO of Medtral New Zealand. Visit www.medtral.com to find out more about accessing world class surgical care in New Zealand.

Traveling overseas for medical procedures involves risk. This risk can be thought of in two broad categories:

1. Risk that is unique to traveling abroad — the travel risk.
2. The normal risk associated with having an operation- the surgical risk.

The Risk of Rraveling Abroad

The risk of the first category includes the unknown quality of the healthcare provided in an overseas hospital and by overseas doctors. Many providers of medical travel have in part mitigated this risk by ensuring that the respective hospitals they use have some form of overseas accreditation. This is usually in the form of accreditation by the Joint Commission International (JCI) but could just as well include all hospitals who countries health accreditation agencies are members of ISQua (the International Society for Quality in Healthcare) of which JCI is but one member.

Additionally, traveling
long distances by airplane involves the risk of the associated effects of dehydration and immobility leading to deep venous thrombosis (DVT) or even the more life threatening pulmonary embolus (PE). While the exact risk of DVTs from long haul flights is a matter for the debate, the WHO Research into Global Hazards of Travel (WRIGHT project) has been initiated as a set of coordinated studies to rigorously evaluate any relationship between DVT and air travel.

Agencies involved in the medical travel, prospective patients and their physicians can alleviate the risk to some extent by ensuring that individuals with high risk medical conditions such as uncontrolled and unstable angina are assessed in their home country first before traveling, and even excluded from long distance travel.

The Risks of Having Surgery

Although many medical travel companies and prospective overseas hospitals have put in place steps to address the first risk, few have steps in place to ensure that people suffering a direct complication from surgery are cared for properly.

Except for carefully screening patients, there is very little a high quality hospital can do to reduce the risk of a surgical complication to zero — there is a universal risk of having surgery. Hence, uncommonly serious adverse events (SAEs) as a direct result of the surgery will occur, and when such complications do occur the results can be quite devastating both physically and financially. Major complications, although now uncommon in most western hospitals, can include: deep tissue infections, myocardial infarction (heart attack), cerebrovascular accidents (CVA or stroke), multiple organ failure and, of course, death.

For example, in coronary artery bypass graft (CABG) surgery the risks of the average American patient having a complication that results in them dying as a result of the surgery vary, but may be between 2-3
percent. The risk of the same patient.....stroke is between 1-2 percent with the possible progression to kidney failure up to 3 percent.

While such complications can occur in the patient’s home country and local hospital, it is in the medical traveler’s best interest to think about how to manage such events if they occur in an overseas hospital. What if the individual becomes incapacitated and not in a position to make decisions about their health?

In such a situation they are dependent upon the doctors in that hospital and to a large degree on the health system of the country where that hospital is located. All of the above mentioned SAEs may mean some time in a hospital’s intensive care unit (ICU), and possible treatment by doctors other that the one who performed their surgery.

Such treatment is extremely expensive and may cost the patient upwards of several hundreds of thousands of dollars if stay in the ICU and the provided treatment is prolonged and complicated. That cost is further increased if they are medically evacuated home.

Medtral New Zealand has designed a package to help alleviate such a risk. Medtral New Zealand is a provider to international medical travelers of high quality non-acute surgical treatment in New Zealand. The hospitals used by Medtral New Zealand are accredited Quality Health New Zealand (QHNZ) which itself is a member of ISQua.

Indeed, managing the surgical risk is one of the first issues that Medtral New Zealand addressed. The company acknowledges there is a universal risk to having surgery, irrespective of the quality of the surgeon or the hospital. Such acknowledgement does not help the patient who has a serious adverse event. To help patients plan for the unexpected, Medtral New Zealand provides contingency insurance as part of their packages to New Zealand to cover this very issue.

Medtral’s contingency insurance allows patients who have a major complication to have:

• up to 60 days prolonged hospitalization in New Zealand including ICU
• medical and surgical treatment to help them recuperate
• if deemed necessary by the treating physician, medical evacuation to the patient’s home country with nurse or doctor attendant, if appropriate.

While such insurance does not reduce the universal risk, it at least provides some needed reassurance for the patient that regardless of the outcome they will be looked after.

Heart Surgery Forum. 5(2):109-13, 2002
Journal of the American College of Cardiology. 43(4):557-64, 2004 Feb 18.
Can J Gastroenterol. 2005 Sep;19(10):613-7.

Leaders of the Medical Tourism Association have been traveling worldwide and working with providers to generate support for the MTA.

In fact, a trip is planned this month to Manila , Philippines, with presentations before the International Medical Travel Conference in Manila , November 22-24, 2007.  Topics will include: “How to attract Americans to your overseas hospital,” as well as “Medical Tourism and the law.”

The Association will be visiting the major hospitals in the Philippines and meeting with government officials within the Philippine government.

Plans are also underway for a visit to Taiwan. The Association was invited by the Taiwan Hospital Association to speak to its member hospitals about medical tourism and the growth of the industry.  We will also visit some of the hospitals in Taiwan.

Look for details of these hospital visits in upcoming issues of the Medical Tourism Magazine, the trade magazine for the medical tourism industry.  Our inaugural issue of the publication will focus on Costa Rica, and subsequent issues will look at opportunities in India.

For more information contact the Medical Tourism Association.
info@medicaltravelauthority.com
www.medicaltravelauthority.com