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BREAKING NEWS

AMA Provides First Ever Guidance on Medical Tourism

CHICAGO, June 16 /PRNewswire-USNewswire/ -- To ensure the safety of patients considering traveling abroad for medical care, new guiding principles on medical tourism were adopted today at the American Medical Association's (AMA) annual policy-making meeting. The nine principles are the first-of-its- kind, and outline steps for care abroad for consideration by patients, employers, insurers and third-parties responsible for coordinating travel outside of the U.S.

"Medical tourism is a small but growing trend among American patients, and it's unclear at this time whether the risks outweigh the benefits," said AMA Board Member J. James Rohack, M.D. "Since this is uncharted waters, it is our hope that the AMA's new guidance on medical tourism will benefit patients considering traveling abroad for health care."

In 2006, an estimated 150,000 Americans received health care overseas, and nearly half of the procedures were for medically necessary surgeries. The emergence of medical tourism is in part a response to the rising cost of health care in the U.S., which puts needed health care out of reach for many, particularly those without health care coverage.

"We need to address the cost of care in the U.S. and cover the uninsured so that every American who needs health care can get it right here at home," said Dr. Rohack. "Until there is significant action at home, patients with limited resources may turn elsewhere for care. It is important that U.S. patients have access to credible information and resources so that the care they receive abroad is safe and effective."

The new AMA principles call for all medical care outside of the U.S. to be voluntary. They address financial incentives, insurance coverage for care abroad and care coordination. The principles also call for patients to be made aware of their legal rights prior to travel and to have access to physician licensing and facility accreditation information prior to travel.

"For those patients considering medical tourism, the new AMA principles are an important starting point for consideration before making the decision to go abroad for health care," said Dr. Rohack.

To ensure that insurance companies and others that facilitate medical tourism adhere to the new principles, the AMA will introduce model legislation for consideration of state lawmakers.

Comment on AMA Guidelines for Medical Tourism

In response to the American Medical Association's "AMA Guidelines on Medical Tourism," adopted 16 June 2008 at its annual policy-making meeting, the International Medical Travel Association (IMTA) applauds the efforts of the American Medical Association to adopt guidelines supportive of patient access to affordable and high quality medical care. The Guidelines on Medical Tourism provide another example of the medical industry's constructively addressing issues raised by the growing trend of patient travel for medical care.

However, addressing the issues faced by patients, physicians, insurers and other medical tourism industry participants requires the cooperative action of industry stakeholders. That is why the IMTA calls on those stakeholders to work with us to further define stan-dards for global medical care and medically-related international travel.

Today, travel is often required when seeking access to high-quality, affordable healthcare services and centers of excellence. Patients, regardless of geographic location, should have free choice in access to medical care. Further, differences or savings in "out of pocket" costs associated with medical services and procedures across different regions should not be viewed pejoratively when comparing elective healthcare at internationally recognized and accredited facilities.

Additionally, the IMTA is deeply concerned with the threat of harmful "medical protectionism" and the potential use of U.S. state and federal legislation to limit patient access to affordable healthcare choices. Of particular concern is resolution 120.971 put forth by the Medical Society of the State of New York, which calls for legislation that precludes insurance companies from offering incentives to patients who are considering crossing borders for healthcare. Such measures, if overzealously adopted, would limit patient choice and run counter to the current state of global healthcare. For example, US executives working abroad must often cross borders for care; what of them? In addition, with increasing globalization, greater numbers of American-trained physicians are working internationally. U.S. training and standards for hospital management are also rapidly increasing internationally. Hospitals such as the Cleveland Clinic, Harvard and Johns Hopkins are either building facilities overseas or aggressively partnering with international healthcare organizations. Any lobbying or legislation toward limiting patient and provider choice must take these important new trends into account.

As patients increasingly carry a personal financial burden associated with their healthcare choices, financial transparency in healthcare transactions is mandated. International medical facilities involved with global healthcare should strive to obtain recognized accreditation. The IMTA has always supported comprehensive coordinated pre- and post-care programs as well as adherence to its "International Patients' Bill of Rights."

While traveling for healthcare may seem to be uncharted waters for many in North Amer-ica, international medical centers have catered to medical tourists for decades, where ac-cess to quality care has always been associated with travel. As U.S. healthcare spending reaches 15 percent of the Gross Domestic Product, equivalent care offered abroad will be increasingly utilized by not only the uninsured but also middle-class families unable to meet large co-pays associated with care in the U.S. Free trade in healthcare services is beneficial to patients as healthcare consumers, and to society, which ultimately bears some of the burden for healthcare services.

The IMTA suggests that relevant stakeholders such as the AMA, representatives of public and private payers, hospital associations, and accrediting bodies-as well as their international equivalents-work with us to further define standards for global medical care and medically-related international travel. Such standards should exemplify coordination and continuity of care across pre-treatment discussion, to intervention, and through recovery, all of which may occur in different locations.

Steven Tucker, MD, FACP
President
International Medical Travel Association

Medical Society of the State of New York Issues Statement Related to Medical Travel

Editor's Note: In its 2008 Position Statements, the Medical Society of the State of New York (MSSNY) included the following related to medical travel.

120.972 Medical Outsourcing: MSSNY to request legislation to prevent insurance companies from incentivizing subscribers in this state to have to go overseas for medical treatment that could be provided locally and, through the American Medical Association, request federal legislation to prevent insurance companies from incentivizing subscribers to go overseas for medical treatment that could be provided locally. (HOD 07-263)

For more information visit:

http://www.mssny.org/mssnycfm/mssnyeditor/File/2008/About_MSSNY/ Position_Statements/2008_Edition.pdf

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SPOTLIGHT
Sharon Kleefied

Sharon Kleefied, faculty member, Harvard Medical School

Sharon Kleefield, former director of Healthcare Quality at Harvard Medical International and currently on the faculty of Harvard Medical School, first became interested in medical travel two years ago when a former colleague asked her to do some investigation on this subject. That investigation provided important insights regarding international medical travel and patient care and the need for ensuring patient safety and quality of care around the globe.

Medical Travel Today recently had the opportunity to talk with her about that vision and her plans for making it a reality.

Medical Travel Today (MTT): First, can you tell us a bit about the nature of the research you were doing that spurred your interest in medical travel?

Sharon Kleefield (SK): Certainly, but first let me mention that I had done a lot of work previously in countries such as India and Thailand, where much of today’s medical travel is taking place. So even when I first began the research, I was already familiar with how the industry worked and who the key players were in the field.

That said, I was asked by a colleague from a major U.S. insurance company to look into the growing trend of patients traveling outside of the U.S. for care and to offer a way of assessing the quality of the care at the centers with the largest volume of patients. This was strictly exploratory, not implementation.

As I started to do the research, I didn’t see a way of comparing or contrasting different hospitals or hospital systems from the patient’s perspective. I was approaching it based on the value equation. That is, "Yes, I can save and probably afford a hip resurfacing procedure, but how do I know I’ll get the best quality?"

I decided to contact individuals who were already involved in the industry to ask them how they were doing it or would do it. I sent inquiries and found wide variations in approach to the question.

I didn’t get anything specific back, but I did get a lot of responses saying, "This is a really important question, and we really need to figure this out. Let us know if you do."

MTT: So that continues to be the question you’re looking to answer?

SK: Yes, but my interest now is more than just research-based. It’s also practical. I’m in the process of formalizing a group of insurers and providers who can get together and actually build consensus on a set of measures or indicators that would provide a window on care at their location.

MTT: Similar to what JCI is doing?

SK: Yes and no, in that I feel very strongly that this needs to be created by the provider institutions, rather than by an outside organization. They need to develop a set of indicators that would be specific to the provision of care across the hospital, but also measures that would be specific to a small set of procedures that are offered to international patients. I’m looking at those that are increasing in number and are more risky for patients, such as hip replacement, hip resurfacing, knee replacement, coronary artery bypass, and valve replacement with a critical view of issues related to appropriateness and continuity of care.

Getting back to the JCI, the hospitals that reach a level of five-star or are the centers of excellence are those that have been accredited by the JCI, or other regional or local accrediting bodies. That’s really the baseline. But none of those accreditations get at the specific kind of indicator measures that go deeply into a stratification of a set of patients by procedure. Their accreditations are more general in nature.

The next level, the one I’m looking to help create, is one that can produce data. What I would call evidence-based indicators related to, not just international patients but to the total number of patients getting those procedures as a whole stratified by procedures and outcomes at a given facility.

So if I needed a knee replacement, I would be able to find out that if I go to, for example, a Bumrungrad or Wockhardt, I would know that during the last year or two they’ve done a given number of knee replacements. And then, what does that mean? Who are the physicians performing most of the procedures? What are the credentials of the physicians? What are the patient outcomes of the procedure? What are the complication rates? What are the infection rates? – just to to suggest a few questions.

MTT: Essentially, patients will have two tiers of quality measures to look at—JCI or a local accrediting body and then the measures you’d provide. Is that correct?

SK: Right. The first level would be an accreditation level they would look for, and then we would provide information based on the institution’s track record for specific procedures. Only institutions that maintain such data sets would be evaluated. It would give them a good benchmark, as well.

MTT: Do you have an idea of where this organization might be centered and who might be involved?

SK: Right now I’m trying to figure out how it would be structured and centered. It
might initially be developed through an established organization or through what I would call a "consensus group." It would be made up of individuals who are involved in providing care for these patients, and are interested in performing health-services research in their hospital.

Many people are interested because it’s needed. Being able to measure quality and safety in a data-driven way is needed. I’ve given several talks at meetings on the subject and am getting a core group of people interested. And I have been working closely with a private hospital group in India that not only carries international accreditation, but also a large enough data set to measure quality and safety for their patients undergoing these procedures.

Those are the types of organization and individuals I’m looking to involve.

MTT: What’s your timeframe for bringing a formalized group together?

SK: I hope to pull together a group in Singapore in February 2009, in conjunction with a conference. I’m also looking to do a workshop or hold group discussions on the subject, to start people thinking and moving towards developing skills in this area.

MTT: It would seem from all that you’re doing you see the potential for a lot of continued growth in medical tourism.

SK: Well, yes, but I don’t know that it’s necessarily going to come from the United States. The latest McKinsey study showed that the rate of growth isn’t necessarily what some anticipated. On the other hand, if you speak to Kurt Schroeder from Bumrungrad, he’ll tell you he’s seeing more and more patients each month. The same is true at Wockhardt in India.

So again, I don’t know how long it will take this industry to grow. If we had a significant change in the healthcare policy in the U.S., it’s better to keep patients here. On the other hand, there are plenty of other patients from other countries who would take advantage of care abroad because the standard of care might be lacking in their own country.

So I think there is growth potential but not necessarily from the U.S.

 

PERSPECTIVES

Medical Tourism: 2008 Survey of Health Care Consumers by Deloitte

A recent survey conducted by Deloitte found that ‘medical tourism’ is a hot trend among U.S. healthcare consumers. Nearly 40 percent said they would travel outside the country for medical treatment, if the quality was comparable and the cost was cut in half.

But the level of interest differed widely by gender, age group, ethnic category, and types of insurance the respondents carried. Most notably, men are much more likely than women to consider a trip abroad for treatment, by a margin of 44.5 to 33.3 percent. Additional highlights:

By Age Group:

  · 51.1 percent of Gen Y would engage in medical tourism
  · 41.9 percent of Gen X
  · 36.7 percent of Baby Boomers
  · 29.1 percent of Seniors

By Ethnic Breakdown:

  · 56.8 percent of Asians are likely to go abroad for less expensive medical
    treatment
  · 51.1 percent of Hispanics
  · 37.8 percent of Caucasians
  · 36.9 percent of African-Americans

By Insurance Category:

  · 40.1 percent of those with commercial insurance
  · 29.9 percent of those with Medicaid
  · 28 percent of those with Medicare

To view the complete survey results, visit:
http://www.deloitte.com/dtt/article/0%2C1002%2Ccid%25253D192707%2C00.html

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INDUSTRY NEWS

Your Medical Travel Newsletter Launches Online Discussion Board and Community for Medical Tourists

ELMWOOD PARK, N.J. - (BUSINESS WIRE) - Responding to the growing interest in medical tourism and the need for consumers to access information about real-life patient experiences or perspectives on traveling outside the country for medical or dental care, Your Medical Travel (www.yourmedicaltravel.com) today introduced a Web-based discussion board: www.yourmedicaltravel.com/forums. As the nation's first consumer newsletter for medical travelers, Your Medical Travel invites visitors to post their own experiences with medical travel, pose questions to others, and share insights.

"We are creating a robust, online community forum where consumers interact and comment upon their medical tourism encounters," says Laura Carabello, publisher and managing editor of Your Medical Travel, noting that the discussion board also allows visitors to create new threads to post additional queries and participate in polls. "Patients can voice their concerns, relay anecdotes, or comment upon the stories in our newsletter. We expect that our readers will find it helpful to connect with others who may have come across similar circumstances—and they may choose to remain anonymous."

A recent study reported in the McKinsey Quarterly projects that the number of medical travelers will grow substantially if certain barriers, such as non-coverage from payers, were removed. The study says that payers and providers looking to benefit from this nascent market have a substantial opportunity.

"This innovative venue is a prime example of social networking where medical travelers can learn from each other and benefit from peer guidance," says Carabello. "It is particularly interesting to learn about new destinations that are offering not only high quality medical care, but also exotic locales for touring or recovering at luxurious wellness spas."

Your Medical Travel is an online publication that reaches both U.S. and international consumers who are interested in medical travel. Its sister publication, Medical Travel Today, circulates worldwide to business audiences, providers, and other stakeholders in medical tourism.

Subscriptions: editor@yourmedicaltravel.com.
Editorial submissions: Amy Rohrbeck, editor, arohrbeck@yourmedicaltravel.com.
Advertising and sponsorships: iandruch@yourmedicaltravel.com.

 

BridgeHealth Introduces its Clients' and Traveling Patients' Rights and Duties

DENVER, Co. – June 16, 2008 – BridgeHealth International, Inc. (www.BridgeHealthInternational.com) today unveiled its patient bill of rights and duties, "Clients’ and Traveling Patients’ Rights and Duties," as part of its focus on giving businesses and individuals an expectation of rights and ethical treatment similar to those provided in U.S. hospitals, along with the highest quality international medical care. Visit http://www.bridgehealthinternational.com/rights-and-duties.html.

"As the premier option for delivering high quality care and treatments to medical travelers, BridgeHealth is committed to meeting client and patient expectations for fair and ethical treatment," says Victor Lazzaro, Jr., CEO of BridgeHealth.  "Medical travel requires collaboration among clients, patients, physicians, and other healthcare professionals every step of the way. Open and honest communication, respect for personal and professional values, and awareness of differences are crucial."
BridgeHealth modeled its "Clients’ and Traveling Patients’ Rights and Duties" on similar guidelines routinely used in the U.S. hospital system.  BridgeHealth clients and traveling patients can expect the right to:

• Receive clear, concise, and timely information about rights and duties, as well as the proper way to exercise them.
• Be informed of the first and last names, professional degree, and position occupied by the health staff providing care.
• Have all the necessary information required to give consent or deny authorization to receive a specific procedure or medical treatment.
• Receive, without any distinction whatsoever, dignified treatment, respect, consideration, and courtesy.
• Receive information with due diligence and efficiency.
• Accept or reject quotes and treatment plans.
• Have access to their files and receive a copy of the same, or authorize a third party access to their files by giving them respective legal authorization
• Demand respect for the confidential nature of clinical history and all information concerning illness except when, by special law, notification must be made to health authorities.
• A timely, thorough, and documented process for registering complaints.
• Receive a detailed statement of account with an explanation of all expenses incurred during treatment.
• Receive visits from family members or friends if desired, as long as health condition permits and visits are within established hours.

“Whether a medical traveler chooses to use distant locations such as Singapore or India or opts to stay closer to home at destinations including Mexico or Costa Rica, BridgeHealth professionals are sensitive to cultural, racial, linguistic, religious, age, gender, and disability concerns,” Lazzaro continues. “By articulating these values, we are demonstrating the importance of remaining involved in this critical intersection of patient welfare and dignity and coordinating patient care outside the United States. Individual well-being is concomitant to our goals and is an overriding concern for maintaining patient dignity and ultimately satisfaction.”

Star Hospitals.net Patients Choose Egg Donors From Their Own Ethnic Background For IVF Treatment

Ontario, Canada – June, 2008 – One in six couples worldwide require some form of reproductive assistance, but infertility services have become cost-prohibitive for many. Star Hospitals (www.starhospitals.net) a North American healthcare service, provides affordable reproductive healthcare in India with a highly regarded team of physicians and healthcare providers that offer cost-effective infertility treatment in state-of-the art facilities.

The opportunity to choose egg donations from different ethnic backgrounds is not readily available in United States and Canada. Star Hospitals provides patients the opportunity to choose egg donors from specific parts of the world. Factors such as physical appearance and family medical history play a significant role in choosing an egg donor, patients benefit from a wide variety of donor choices.

"We are confident that our infertility services are equal or superior to the treatment available at U.S. clinics – at a fraction of the cost and with exceptional success rates," says Kumar Jagadeesan, vice president of Star Hospitals. "The success rate of in vitro fertilization (IVF) or intracytoplasmic sperm injection (ICSI) treatment in India is 25 to 50 percent per attempted cycle, identical to the success rate in the U.S."

IVF is a process in which an egg is fertilized by a sperm outside the woman’s womb. Once the fertilized egg becomes an embryo, it is transferred into the uterus. This procedure can cost approximately $12,000 per cycle in the United States. The process can vary depending on the treatment modality required for a successful pregnancy. Star hospitals facilitates ART (Assisted Reproductive Techniques) at a fraction of the cost even after considering travel expenses.

The likelihood of pregnancy resulting from IVF depends on the cause of infertility, age of the patient, and the infertility treatment approach. Star Hospitals works individually with each patient to address all questions and concerns.

"The comfort and care of each individual are our primary concerns," emphasizes Jagadeesan. "Each situation is closely evaluated on a personal level before any action is taken."

Star Hospitals helps patients make travel arrangements, including visas and passports, accommodations, and sightseeing. A companion program is also available for anyone accompanying the patient.

For a free consultation please call our toll free number 1 888 7827 012 and speak to our doctor or visit our website.

About Star Hospitals

Star Hospitals is a North American health care service offering affordable and timely treatment abroad through a network of hospitals throughout India, Singapore and Thailand. For more information please visit www.starhospitals.net or call 1-888-STAR-012

Mexico’s First Internationally Accredited Hospital Partners with Sekure Healthcare and IntelHealthGroup

SAN DIEGO — Responding to the growing U.S. consumer demand for safe and affordable healthcare in Mexico, Sekure Healthcare announced an innovative agreement with CHRISTUS Muguerza and IntelHealthGroup. The agreement allows Sekure Healthcare Members to utilize their insurance benefits at CHRISTUS Muguerza Alta Especialidad Hospital in Monterrey—Mexico’s first hospital accredited by the Joint Commission International (http://www.jointcommissioninternational.org). Additionally, IntelHealthGroup, which facilitates access to quality medical facilities in Mexico, will provide its services to Sekure Healthcare Members and to those wishing to travel to Mexico for their healthcare needs. By joining forces, these three organizations are providing healthcare options previously lacking in the market.

The CHRISTUS Muguerza Alta Especialidad Hospital is located in Mexico’s third largest city, Monterrey. “Our philosophy for patient care and commitment to quality assurance has been demonstrated by the Joint Commission International accreditation,” said Arturo Garza-Buerón, CEO of Grupo CHRISTUS MUGUERZA. Garza-Buerón adds, “We are now focusing on building alliances to increase our visibility as a quality healthcare provider for consumers in Mexico as well as in the United States.”

CHRISTUS Muguerza is affiliated with CHRISTUS Health, a U.S. healthcare system based in Dallas, Texas, with 40 hospitals, inpatient facilities, and dozens of clinics in more than 70 cities in North America.

Sekure Healthcare is focused on delivering cost-effective solutions to U.S. employers who cannot afford traditional major medical insurance. “We have been at the forefront of developing affordable coverage using limited benefits insurance, which also allows beneficiaries to access their benefits in the U.S. as well as throughout the interior of Mexico. The agreement with CHRISTUS Muguerza and IntelHealthGroup opens the door for a new stage of consumer choice and quality assurance,” said Jim Arriola, CEO of Sekure Healthcare. “Seventy-four percent of our members are Spanish-speakers. To better serve the Latino segment of our membership, we have expanded our California network of community clinics and have also grown our cross-border network to include providers in more than 400 cities and towns throughout Mexico. Adding CHRISTUS Muguerza Alta Especialidad Hospital to our network coupled with the support of IntelHealthGroup gives our members the quality assurance in Mexico they are looking for,” adds Arriola.

IntelHealthGroup, a leading healthcare consulting and medical travel company, guides its clients to quality healthcare institutions in Mexico. “We provide personalized assistance to our client/patients throughout the process including their stay in Mexico,” says CEO Dr. Jaime Zozaya. He adds, “Our trained staff, which includes medical professionals, personally guide each customer every step of the way to ensure they feel at home while they get the medical attention they seek.”

The Sekure Healthcare, CHRISTUS Muguerza and IntelHealthGroup Accords also benefit English-speaking consumers who are considering traveling to Mexico for medical care. “These types of alliances may have more Americans contemplating medical travel to Mexico,” says Dr. Enrique Ruelas, Surgeon General of Mexico. “If medical savings are significant and consumers are assured of demonstrated quality combined with ease of process, then more U.S. consumers will view Mexico as a viable alternative.”

Treatment Abroad Launches Online Patient Reviews

Treatment Abroad, the leading online medical tourism portal, has launched a ratings and review system for medical tourists to share and rate their experiences of traveling overseas for medical treatment.

The website, which already carries testimonials from patients who have undergone cosmetic, elective surgery, and dental treatment abroad, will now encourage patients to add ratings and reviews of individual hospitals, clinics, and medical tourism agencies. www.treatmentabroad.com is the most visited health tourism site in Europe. With over 70,000 visitors a month, the website provides up-to-date information and advice about surgery and treatment in more than 30 countries. The Ratings and Reviews service has been introduced to enable prospective patients to benefit from the experiences of previous patients.

Ratings and reviews are available through the Treatment Abroad site and on a dedicated reviews microsite: http://reviews.treatmentabroad.com.

A recent UK study found that 97 percent of consumers are willing to trust online reviews. Keith Pollard, Managing Director of Treatment Abroad says: “The Ratings and Reviews service is intended to inform patient choice. Patients need to be clued up on overseas medical treatment, and some may be apprehensive about the risks of traveling for treatment. Patients who have become ‘medical tourists’ generally tend to be extremely positive about their experience, so the addition of ratings and reviews on the site will further build patient confidence.”

The technology behind the Ratings and Reviews service is supplied by Bazaarvoice, whose clients include leading national and international brands like Dell, Early Learning Centre, and Hewlett Packard.

The recently published Treatment Abroad 2008 Patient Survey found that 96 percent of patients traveling overseas for treatment would return to the same treatment provider. The new patient rating service will enable patients to share with others their experiences of medical tourism agencies, hospitals, clinics, and dental practices. “The more opinions a patient can gather, the more secure they feel with their ultimate choice,” comments Pollard.

Medical tourism is growing rapidly throughout the world, and Treatment Abroad is always striving to provide as much information as possible to help patients make the right decision when choosing where to go for treatment. In addition to the introduction of consumer reviews, the site has also launched a new “Code of Medical Practice.” The new code sets a standard for “best practice” among healthcare providers, giving patients further reassurance and the accountability that they need when making healthcare choices.

New Medical Tourism Website Brings Competitors Together

Singapore - A new medical tourism website has brought competitors from Singapore and Thailand together on a single platform, a published report said on Thursday.

Called FlyFreeForHealth, it has six healthcare partners on its list, including Thailand's Phyathai Hospitals Group.

“Given the U.S. recession and an increasingly inefficient healthcare system in Europe, the launch of FlyFreeForHealth is definitely well timed to meet the demands of these medical travellers,” The Business Times quoted founder Wei Siang Yu as saying.

Accommodation-service providers and spa operators are also on the list.

A membership concept allows medical tourists to benefit from savings and partial rebates if they sign up for programs costing 200 U.S. dollars to 5,000 U.S. dollars a year.

Wei said he is aiming to secure at least 20 partners and 2,000 members a month starting in August.

The company has signed an agreement with Indonesia's West Java Chamber of Commerce and Industry, giving it access to more than 350,000 corporate clients, the report said.

New Study: 25 Million U.S. Adults Are Underinsured

The number of underinsured U.S. adults—that is, people who have health coverage that does not adequately protect them from high medical expenses—has risen dramatically, a Commonwealth Fund study finds. As of 2007, there were an estimated 25 million underinsured adults in the U. S.—up 60 percent from 2003.

Much of this growth comes from the ranks of the middle class. While low-income people remain vulnerable, middle-income families have been hit hardest. For adults with incomes above 200 percent of the federal poverty level (about $40,000 per year for a family), the underinsured rates nearly tripled since 2003.

These results and others are published in How Many Are Underinsured? Trends Among U.S. Adults, 2003 and 2007, (Health Affairs Web Exclusive, June 10, 2008), by The Commonwealth Fund's Cathy Schoen, Sara R. Collins, Jennifer L. Kriss, and Michelle M. Doty.

Middle-Income Uninsured Rate Rising

The authors analyzed data from the Commonwealth Fund 2007 Biennial Health Insurance Survey, which interviewed adults ages 19 and older from June through October 2007. Respondents were identified as underinsured if they spent 10 percent or more of their income (or 5 percent if they were low-income) on out-of-pocket medical expenses, or if they had deductibles that equaled 5 percent or more of their income. An estimated 14 percent of all non-elderly adults were underinsured in 2007, and more than one in four were uninsured for all or part of the year. Adding these two groups together, 75 million adults—42 percent of the under-65 population—had either no insurance or inadequate insurance in 2007, up from 35 percent in 2003.

Lack of adequate insurance coverage, the study finds, is not a problem limited to low-income people. Adults with incomes below the poverty level were at the highest risk of being uninsured or underinsured, but "insurance erosion has spread up the income distribution well in to the middle-income range," the authors say. For those with annual incomes of $40,000 to $59,000, the underinsured percentage rate reached double digits in 2007. Barely half of those with incomes of 200 percent to 299 percent of the poverty level were insured all year with adequate coverage.

Underinsured Go Without Needed Care

In terms of access problems and financial stress, underinsured people—even though they have coverage all year—report experiences similar to the uninsured. More than half of the underinsured (53 percent) and two-thirds of the uninsured (68 percent) went without needed care—including not seeing a doctor when sick, not filling prescriptions, and not following up on recommended tests or treatment. Only 31 percent of insured adults went without such care.

About half of the underinsured (45 percent) and uninsured (51 percent) reported difficulty paying bills, being contacted by collection agencies for unpaid bills, or changing their way of life to pay medical bills. Many reported that they took on a loan, a mortgage against their home, or credit card debt to pay their bills, suggesting "that these financial difficulties had the potential to linger into the future." In contrast, only 21 percent of insured adults reported financial stress related to medical bills.

Benefit Design Matters

The sharp increase in the number of underinsured adults, say the authors, is partly due to design changes in insurance benefits that leave individuals financially vulnerable. Underinsured adults were more likely than those with adequate insurance to report benefit limits—for example, restrictions on the total amount a plan would pay for medical care or on the number of physicians' visits allowed. They were also far more likely to report high deductibles: one-quarter had annual per-person deductibles of $1,000 or more. Despite benefit limits and higher deductibles, underinsured adults often reported high annual premium costs, in line with those reported by more adequately insured people.

"Benefit design matters," the researchers conclude. Having a policy with substantial cost-sharing relative to income can undermine access to care and erode family finances. While improving insurance coverage is a worthy goal, it is important for policymakers to consider cost-sharing provisions, scope of benefits, and income when exploring coverage mandates, they say. Healthcare reform in Massachusetts, for example, includes graduated cost-sharing, as well as premium assistance for those with incomes up to 300 percent of the poverty level.

The goal is high-quality care and improved outcomes—not just coverage, write the authors. "[T]here is growing recognition of the need for coherent strategies that combine coverage with payment and other policies to change directions and move toward a more inclusive and higher-performing, high-value health system."

Citation
C. Schoen, S. R. Collins, J. L. Kriss, M. M. Doty, How Many Are Underinsured? Trends Among U.S. Adults, 2003 and 2007, The Commonwealth Fund, June 2008

Kaiser, Microsoft Partner on Online Health Records Pilot

On Monday, Kaiser Permanente announced it would partner with Microsoft to create a pilot project that will link Kaiser's patient data with Microsoft's personal health record service, the New York Times reports.

The pilot project, which initially will only be available to Kaiser's 156,000 employees, will link patient information from the Kaiser's My Health Manager PHR with Microsoft's HealthVault PHR tool. The pilot will run until November.

If the project is successful, Kaiser will offer the service to all of its 8.7 million members in nine states and Washington, D.C. (Lohr, New York Times, 6/10).

During the pilot stage, Kaiser will be testing the program's security to ensure it meets safety standards, according to Anna-Lisa Silvestre, Kaiser's vice president of online services (Lawton, Wall Street Journal, 6/9).

Similar online PHR initiatives are under way by companies such as Revolution Health and Google (Beasley, Reuters/Washington Post, 6/9).

Kaiser and Microsoft officials said the pilot program's long-term goal is to bring more medical data online and provide patients with the ability to share their data with healthcare providers and pharmacies.

Peter Neupert, a Microsoft corporate vice president, said that another goal of the project is to be able to transfer information from HealthVault to Kaiser's PHR system (Wall Street Journal, 6/9). He added, "We think we can start to transform the management of chronic conditions."

Silvestre said Kaiser also considered partnering with Google but was impressed with Microsoft's technology for protecting the privacy and security of personal data. She added that Microsoft uses the same Web-based format – called Continuity of Care Document – that Kaiser uses. Google is using a different Web-based format, called Continuity of Care Record (New York Times, 6/9).

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MEDICAL SPOTLIGHT: Bariatrics

According to the World Health Organization (WHO), obesity has reached epidemic proportions globally. WHO estimates that there are more than 1 billion adults who are overweight with at least 300 million of them being clinically obese. Obesity is now considered a major contributor to the global burden of chronic disease and disability and leads to a number of related health conditions, including but not limited to diabetes, high blood pressure, sleep disorders, and high cholesterol. In many instances, obesity-related conditions can lead to poor performance or attendance at work and an overall poor quality of life.

For many, bariatric surgery offers an effective way for patients to regain their health, return to work, and re-establish a desirable quality of life.

However, because of the required counseling, criteria for surgery, expense, and, in some cases, lengthy wait times, many people are going abroad for treatment. The options for consumers are numerous. Available procedures include gastric bypass, laparoscopic adjustable gastric banding (LAP band), gastric sleeve, and duodenal switch. These procedures are being performed in virtually every medical travel destination including India, Mexico, Thailand, Singapore, and Israel.

According to Elliot Goodman, M.D., Assistant Professor of Surgery, Albert Einstine Medical Center, “The cost on average for bariatric procedures in the U.S. is roughly $15,000 to $30,000 and in the UK it’s $20,000. But what patients are discovering is that they can go to Mexico, the Caribbean, Israel, or India and get it done for $8,000 to $12,000. And that’s without the three-to-four-year wait time that one might face in, say, Canada.”

Goodman also notes that LAP band procedures are more common in Europe and Israel because it’s both “less expensive and less invasive.” However, as obesity rates continue to climb around the globe, he anticipates an uptick in the number of gastric bypass procedures being performed in Europe.

“This is, in all likelihood, a reflection of Europeans essentially catching up with Americans in terms of the type of diet they’re eating and the lack of portion control,” says Goodman. “Until we regain control of our diets, I would expect the number of bariatric procedures taking place worldwide to continue to grow.”

Saroja Mohanasundaram, CEO of Healthbase reports, "We mostly get customers who are either un- or under-insured. But in the case of bariatric surgery, we receive even those patients who have health insurance. These patients tend to find it difficult to get insurers to cover bariatric surgeries."

Most of Healthbase’s bariatric patients receive LAP band and gastric bypass surgeries. According to Mohanasundaram, the most popular destinations for these procedures include Mexico, Costa Rica, India, and Thailand.

Stephanie Sulger, vice president of the Consumer Division at BridgeHealth International, Inc., reports, "Many patients opt to travel to Central America because of the convenience, extensive experience, quality and cost savings. Bariatric surgery and LAP band procedures are often not a covered benefit, even if the individual has an otherwise excellent plan. At BHI, we also have 30 locations in the United States for post-op follow up care which is necessary for this type of surgery."

A cost comparison of various procedures available in the U.S., India, and Thailand are listed below (in USD) according to medicalworldtravel.com:

PROCEDURE	THAILAND	NORTH AMERICA	INDIA
Obesity Surgery (Gastric Bypass)	$13,000	$65,000	$9,500
Tummy Tuck	$4,200	$6,400	$3,100

For more information on bariatrics, click here.

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