Medical Travel Today

SPOTLIGHT
Thomas Johnsrud

Editor's Note: In our last issue we featured an interview with Sharon Kleefield of Harvard University. If any one would like to contact her with regard to her efforts in medical travel, please contact her at: skleefield@hms.harvard.edu

Thomas Johnsrud, Senior Consultant, North America
Parkway Group Healthcare

In Issue 15 of Medical Travel Today we spoke with Peter Hayes of Hannaford Brothers, Inc. regarding the company’s decision to add medical travel to its employee benefits package. Now, we talk with Tom Johnsrud, a senior consultant with Parkway Group Healthcare, about its efforts to promote medical travel to employers; the challenges they face in this marketing effort; and his predictions for the future.

Medical Travel Today (MTT): If you would, first please tell us a bit about your background and how you came to work with Parkway.

Tom Johnsrud (TJ): I’ve actually been involved in healthcare management for the past 20 years working in the areas of business development, operations, performance, and quality improvement at a number of facilities across the country. Most recently I was the Director of Accreditation Operations with The Joint Commission (JC). I also worked with Joint Commission Resources, an affiliate and the official publisher and educator of the JC focused on domestic and international consulting and accreditation preparation.

In that role I became keenly aware of the growth and evolution of medical travel both here and abroad. My exposure to the international healthcare community showed me the level of care that was being delivered overseas. The opportunity to be a part of that growth by working with Parkway presented itself just over a year ago. It looked both exciting and promising, so I decided to pursue it. And here we are.

MTT: As a Parkway consultant, who do you spend most of your time talking with, and what’s the nature of the discussions?

TJ: Maybe a better question is who don’t we talk to?! In the past few weeks I’ve had conversations with insurers, employers, Third Party Administrators (TPAs), and brokers.

There’s still a great deal of education that needs to take place on many, many levels.

On the employer side, a lot of the people with whom we talk have received queries from employees about medical travel, and the employers don’t really know where to go for information. That’s where we step in. We explain how the process works; we dispel some of the myths about it; and offer some assurances that medical travel is a truly valid and worthwhile benefit to offer employees.

A lot of our recent discussions have been with business groups that represent a number of small self-insured businesses. These organizations are generally in a better position to begin offering medical travel and are motivated to do so—once we educate them—because it saves them money; shares much of the savings with their employees; and gives their employees some options Once they understand that, they become increasingly interested.

MTT: How challenging is it to get them to that point of understanding?

TJ: It really depends. Most employers still don’t know about medical tourism, or if they’ve heard something they’re questioning if it’s legitimate. We spend a good bit of time educating them to the fact that their employees are going to get as good of care if not better than what they’d get from their local provider. They’re looking for assurance that this is a safe option for their employees.

There’s also concern about what their employees and the greater community will think of the benefit. Will they understand what a great option it is, or will they simply see it as the company trying to save a buck?

We usually dedicate a lot of time to talking about community perceptions and community education. You know, the truth is that we’ve done focus groups for a major insurance company about perceptions. We know that focus groups were held in the communities near Johns Hopkins, Mayo, and the Cleveland Clinic to learn how the community members perceive care. When probed about their experience at U.S. hospitals, we found that it wasn’t always the best experience. Not that the medical care was bad, but the whole patient experience wasn’t great.

Then we share how international hospitals operate in the area of patient care and the fact that patients are increasingly concerned about customer service. The idea of concierge care is hard for some people to put their minds around, but that is the standard of care. You are treated extremely, EXTREMELY, well.

We also spend a lot of time coaching them on how to present this benefit to employees. We want to encourage them to really promote the option, not keep it hush-hush. At this point in time, medical travel is becoming so well understood by consumers that offering it could actually be a recruitment benefit.

MTT: How concerned do employers tend to be about pre- and post-operative care?

TJ: Oh, that’s definitely a concern, as it should be. Parkway has several international representatives working with different countries. They are the liaisons between the domestic and treating physicians to ensure continuity of care. The representatives are assigned to clinical specialties so they’re extremely familiar with the types of information exchanges that are required before a patient travels or even agrees to a procedure.

And it’s not just the representatives. The specialists are highly involved in each case. We actually had a case where an individual from the United States was touring several international facilities. He was planning to come to Parkway after visiting a hospital in another country. He was preparing for his flight to Singapore when he had a medical situation.

He called the liaison at Parkway and explained what was happening. Parkway’s representative initiated the contact with the appropriate medical staff, who arranged to meet and triage the visitor at the airport, accompanied by necessary ground transportation. Although that’s not the typical way patients are greeted, it is indicative of the level of involvement of the entire staff.

That’s simply how care is provided.

MTT: I recently read a press release that Parkway was building the “hospital of the future.” Can you tell us what that’s about?

TJ: Singapore is very interested in medical tourism and recently put projects up to bid to address the needs of patients from around the world. Parkway secured a bid to build a new hospital, Novena. It’s a 350-bed, state-of-the-art hospital with all the amenities for all the various populations served.

For example, the cafeteria of the hospital needs to cater to a variety of ethnicities and dietary needs. You’ve got to offer several cuisine options for the populations served—Muslim, Chinese, Kosher, Western, European, and so on.

And it’s not just the foods. Even the rooms need to be designed to accommodate various religious needs. So, for example, a certain number of rooms need to face a given direction to accommodate daily prayer requirements, etc.

The new building is slated to be completed in 2011 and will have 350 beds, an extensive diagnostic and treatment unit, medical suites, and an ancillary unit. The design is quite compelling and incorporates a number of elements of sustainable design. It’s truly an exciting project.

About Tom Johnsrud
Mr. Johnsrud is an executive with more than 20 years of leadership experience in a wide variety of healthcare settings. Past experience includes Executive Director/Administrator positions in a number of skilled nursing and rehabilitation facilities across the United States and director positions in several acute care tertiary and acute rehabilitation hospitals. He joined Joint Commission Resources, the consulting division of The Joint Commission, in 2004, where he had most of the responsibility for the domestic consulting operations as well as involvement with international consultant management. He was then promoted to Director of Accreditation Operations for The Joint Commission responsible for overseeing the accreditation division’s planning and budgeting.

Mr. Johnsrud is currently the senior consultant for ParkwayHealth, a leading provider of healthcare services in Asia, headquartered in Singapore.

SPOTLIGHT
Arthur L. Burnett, M.D., F.A.C.S.

Arthur L. Burnett, M.D., F.A.C.S.
Professor, Department of Urology, Director of the Basic Science Laboratory in Neuro-urology
Johns Hopkins University

The Johns Hopkins Hospital and The Brady Urological Institute have been ranked the #1 hospital and Urology Department in America by U.S. News & World Report (most recent 2007) for over 16 consecutive years.

Medical Travel Today’s publisher, Laura Carabello, recently had the opportunity to speak with Arthur L. Burnett, M.D., F.A.C.S. who is a professor in the Department of Urology at Johns Hopkins University and Director of the Basic Science Laboratory in Neuro-urology about the impact medical travel is having on his particular field and how Johns Hopkins Hospital is responding.

Medical Travel Today (MTT): Do you currently treat patients who travel to the United States for medical care?

Arthur L. Burnett (AB): Yes. My activities are primarily at Johns Hopkins Hospital in Baltimore where I probably operate on international patients a few times a month. The patients that I treat travel here from every part of the world.

We have a very big international office, and you might gather or otherwise know that Hopkins—and perhaps all the other major institutions—do align their programs with various other hospitals and companies. These relationships are certainly beyond Baltimore, Maryland, and include locations such as Turkey, Panama, and elsewhere.

MTT: If you had to characterize the impact of medical tourism on the marketplace today, are there any observations that you would want to make?

AB: It seems to be a growing phenomenon. I am still trying to get a real pulse for the statistical data and how much impact it can have on healthcare and the market. Clearly, the underinsured or uninsured people are giving it serious consideration.

Rising expenditures in the United States are driving a lot of this interest, and there’s a bit of academic interest which is, at this point, more theoretical. What is interesting is whether any level of change with medical travel is likely to impact the healthcare market of the United States and make American businesses become more competitive for the healthcare dollar.

MTT: Are there any urological procedures that you would point to -- for both men and women -- that may prompt people to travel outside the United States? This might include surgeries where people don’t have access to care or can’t afford the price tag.

AB: It would be very interesting to think about that. Certainly, when you think about stem cell transplants or even stem cell therapy, individuals may be prompted to leave the country. There are not too many urologic procedures that would be impacted, but organ transplantation comes to mind. There are many transplant surgeons here – and abroad – who focus entirely on this specialty.

Some of the other areas of urology are highly technologically driven and American providers may be dominant in trying to bring all these technologies here. In some cases, it’s the other way around.

I do think that the majority of services, specifically in urology, are readily available in the United States, but I suppose economic factors could drive people to try and explore many kinds of urological procedures elsewhere. One of the nice things about urology, and one of the reasons I selected this specialty, is that it requires a high degree of training and skill. Most procedures are semi-elective or even elective. So I think that seeking urologic care elsewhere in the world would require some investigation of the credentials and experience of the providers.

Generally, urology procedures do not make it difficult for travel, although there are some safety risks for some of the procedures. Acute procedures, I would think, should stay in the United States or close to home.

MTT: Let me ask you a sensitive question: For gender reassignment, is this a procedure that people are able to get here—are they sensitive about undergoing it in the United States,, or would they prefer traveling to another country, such as Bangkok?

AB: It could be, but certainly not too many of us have this as a major area of practice in the United States. Here at Johns Hopkins, we had practice experience as far back as 30 to 40 years ago.

I think patients have a lot of concerns about this process, and there are great social and psychological issues. Complete packages of care are required, and it is appropriate in situations where there truly is a medical problem. Gender reassignment carries a whole lot of non-surgical management problems, and most surgeons shy away from those types of surgical patients.

I’ve been reading a lot about these patients and procedures in Southeast Asia, and there are many concerns, particularly the psychological impact. This is just not something that my practice is involved with.

MTT: What is your opinion about urologic cancer treatments, such as the ultrasound treatments now available in Mexico? Should people take advantage of these non-FDA approved procedures?

AB: What’s going on is that there is a high interest in ultrasound therapies and the techniques involved. The very nature of non-invasive ultrasound waves make this attractive in targeting specific areas of the body or organs. While ultrasound testing is highly attractive, the challenge is that outside this country, they may not maintain the same high level of standards as we have here in the United States. The American Urological Association and other organizations require proof of therapy, which may not be required elsewhere.

We are not ready to embrace this specific type of ultrasound therapy because we’re very concerned that this therapy has not demonstrated long-term efficacy. Nonetheless, U.S. patients are attracted to take advantage of this option and I’m sure patients are traveling outside the United States to explore this treatment.

MTT: If you are a U.S. patient and need urological surgery, what would prompt you to leave the country – say, Singapore or India—to have it done?

AB: I wonder why people would leave the United States. You know, my background and tradition have always been that we have the best care here. What is it about these other countries that is making them so attractive, particularly for urology? What prompts people to leave the United States?

I think that the traditional things are access, cost, and perhaps just newer therapies that they perceive as better but that are not approved in the United States. And correctly, all these sorts of things are probably not major concerns for much of urology.

Yet, I think that all those things are potential magnets, with economics playing the biggest role in the decision to leave the country. Some people, particularly the uninsured, are encountering huge cost for urologic care, and there are less costly options elsewhere in the world.

MTT: What about kidney donors and organ transplants? There are many horror stories about people being spirited away in the night and people removing their kidneys. What is your take?

AB: I’m not sure I know the real facts but sense that most centers have restrictions and operate in a highly regulated way.

MTT: In other words, are kidneys readily available here in the United States?

AB: No—I think that transplant organs are limited. At Hopkins, we do play a role in organ transplantation and actually have dedicated transplant surgeons to really carry out that practice. My personal activities in this area are limited.

MTT: Is there anything that you think would be more appropriate to women or men in the practice of urology in terms of their interest in leaving the country? Would you predict or would you envision more women leaving or men leaving for procedures?

AB: I don’t think that there would be any gender differences. In urology, it tends to be more male-oriented in general, which could account for some differences. Overall, women and men are facing certain kinds of common cancers such as cancer of the bladder or kidney.

MTT: How about age?

AB: I’m not sure if this is an age-based discussion since urologic diseases span all ages.

MTT: Should employers look at locations outside of the United States to save money on urological procedures?

AB: You know, I’ve certainly read about this but would think that it may be limited. I do think that employers would want to seek the opportunity but may need to think more carefully about how they’re reducing expenditures. Employers need to assess how they’re spending money for employee healthcare and will want to explore the benefits of medical travel. Ultimately, they will have to figure out how are they going to deal with providing benefits and coverage, and perhaps for some minor procedures, less expensive providers outside our borders may be viable. However, employers have a very real responsibility to patient safety, and a lot of companies are facing this crunch to ensure quality and lower costs.

MTT: Do you foresee more robust relationships between an institution like John Hopkins and other institutions with foreign medical centers?

AB: Yes. I think that this is probably going to expand with co-branding and marketing. We see growth in the international markets and increased discussions about the ramifications of expanding into foreign countries. As American consumers decide to leave this country, the trend will either help or detract from our economy, depending upon the reaction of domestic hospitals and providers.

MTT: Are you personally partnering, or do you see opportunities to partner with hospitals in other countries?

AB: Being a full-time surgeon at John Hopkins pretty much locks up my schedule, with some time also devoted to research and laboratory activities. I just can’t extend my practice internationally at this time, but it’s certainly attractive to me and would require a different commitment.

MTT: Would you point to any specific country or area of the world that would hold more interest for you than others?

AB: One area that has a lot of interest for me is the Caribbean. As a prostate cancer surgeon, I view this geographic area with great concern since there is a high incidence of disease and a need for education and prevention.

MTT: What part of the Caribbean interests you?

AB: Jamaica and Bahamas are of special interest, and I am trying to interact with all the stakeholders in those areas.

About Arthur L. Burnett
Arthur L. Burnett, II, M.D., is Professor, Department of Urology, at Johns Hopkins University School of Medicine, where he is also Director of the Basic Science Laboratory in Neuro-urology. Currently, Dr. Burnett holds professional appointments at the Johns Hopkins Hospital, including Director of the Male Consultation Clinic and clinician-scientist at the James Buchanan Brady Urological Institute.

PERSPECTIVES

IMTA Challenges U.S. Doctors and Insurers to Follow AMA Directive for Medical Travel

WASHINGTON, D.C. – June 23, 2008 – Urging U.S. employers, insurers, and physicians to provide follow-up care for returning medical tourists, the American Medical Association (AMA) recognizes that Americans have the right to travel outside the United States for medical treatment, states the International Medical Travel Association (IMTA; www.intlmta.org), a global organization that represents leading healthcare providers and medical travel facilitators around the world.

"This is a significant development in changing how and where Americans receive healthcare in the future,” says Steven Tucker, M.D., president of the IMTA and a leading U.S. board-certified medical oncologist. “By issuing guidelines on medical tourism, the AMA is acknowledging the right of patients to seek affordable and quality medical care anywhere in the world, and we hope America’s doctors and insurance companies are listening."

The IMTA points out that some U.S. physicians disparage patients who have gone abroad for surgery. As a result, returning patients who have continuing care needs or develop complications frequently must get help at hospital emergency rooms or from unfamiliar doctors.

"With a lack of guidelines for physicians, international patients are often treated like pariahs," adds Dr. Tucker. "Continuity of care is the number one concern of patients, and they often need their hometown doctor’s support. The AMA’s position represents a major change, and one that we support: international patients should not be penalized, and they should be treated the same as any other patient for after-care."

He says that financial liability, not currently addressed in the AMA guidelines, is still the major concern for those caring for medical travelers.

"The IMTA expects this will be addressed soon as a growing number of Americans choose to travel abroad for quality medical care," concludes Dr. Tucker.

About IMTA
The International Medical Travel Association is a global organization of stakeholders in the international medical travel industry, representing leading healthcare providers, medical travel facilitators, and related industry service providers around the world. IMTA supports the development of international industry standards and best practices that promote and advance medical quality, safety, and transparency for the international patient, and that preserve and protect the doctor-patient relationship. IMTA, www.intlmta.org, is a not-for-profit association funded by membership dues and programs.

INDUSTRY NEWS

Medtral New Zealand announces partnership with MA-based Pinnacle Health: A ground-breaking industry alliance

Auckland, NZ/MARLBOROUGH, Mass. —June 23, 2008 - Medtral New Zealand (www.medtral.com), providing, world-class, affordable healthcare, with all-inclusive travel and medical treatment packages, today announced a ground-breaking partnership with Pinnacle Health (www.pinnaclehealth.com), a preferred provider organization providing network and administrative services to self-funded employers, with over 3,000 providers throughout America’s Northeast.

According to Paul Brough, president and CEO of Pinnacle Health, "This relationship holds significant potential for both organizations. An attractive destination for medical care and surgery, New Zealand pushes all the right buttons for me. It’s a first world, English-speaking country with very high quality medicine and a clean, green environment that is ideal for recuperation. Additionally, the quality and affordability of the travel and treatment packages is unparalleled. Our customers are now requesting options for medical travel, and New Zealand fits the bill."

Medtral New Zealand services include travel, accommodation, hospital procedures, and post-operative care at New Zealand’s premier private medical facilities and contingency insurance. Adhering to Quality Health New Zealand (QHNZ) and International Society for Quality in Health Care (ISQua) accreditation standards, Medtral New Zealand’s network of hospitals provides a world-class experience and service for North American patients.

We are excited about the prospects of working with a forward-thinking organization like Pinnacle Health," says Steve Nichols, managing director of Medtral New Zealand. "This partnership offers an affordable and attractive option to Pinnacle clients and members, and makes sense for the self-funded employers that are considering medical travel options for their employees."

Nichols emphasizes that the option of medical travel to New Zealand will undoubtedly save Pinnacle member employers significant costs while ensuring the quality of the medical services.

"Patients get the chance to experience New Zealand and enjoy dedicated recovery time at potentially less personal cost than having the operation performed in the United States," adds Nichols.

ParkwayHealth’s Living Donor Liver Transplant Program Continues to Meet Patient Demands

Chicago, Ill. /Singapore- June 9, 2008- Parkway Health, (www.parkwayhealth.com), Asia's leading healthcare provider with the largest network of private hospitals and healthcare services headquartered in Singapore and the first in Asia to perform a living donor liver transplant (LDLT) in 2002, reports that its Gleneagles Hospital has performed over one hundred successful LDLT procedures to date. With the full program in place, the hospital expects to perform about 50 procedures annually.

"Since its inception, the LDLT program has provided an exceptional, quality-focused program, with milestones that include the first pediatric and adult living transfers in Asia," says Thomas Johnsrud, consultant for Parkway Health North America.

LDLT is a procedure in which a diseased liver is replaced with a segment of liver from a healthy human donor, usually a sibling or close family member. Living donor liver transplantation can be performed on anyone with end-stage liver disease regardless of the original cause of their disease.

"The success of liver transplantation at Gleneagles has resulted in a dramatic increase in the number of patients who are now being considered for this operation," says Johnsrud, noting that in 2007, there were 17,440 patients waiting for a liver transplant in the United States. "The number of cadaver donors available for transplantation was simply insufficient, a factor which led to the development of the LDLT program."

Gleneagles program director Tan Kai-Chah, M.D., a pioneer in the LDLT procedure, has performed more than 500 liver transplants in Britain, Singapore and Malaysia. He leads the team which comprises experts from various specialties, with expertise and extensive experience in major hepatobiliary and liver transplantation surgery.

With an ongoing and increasing shortage of cadaver livers, transplant centers in Asia have adopted living donation as a partial solution to this shortage. Individuals now recognize that by donating a portion of their liver to a relative, friend or co-worker, they can make give the gift of life.

About ParkwayHealth
Parkway Health is Asia's leading healthcare provider with the largest network of private hospitals and healthcare services headquartered in Singapore. Parkway Holdings Limited (PHL) owns Parkway Hospitals Singapore Pte Ltd which runs East Shore Hospital, Gleneagles Hospital, Mount Elizabeth Hospital and ParkwayHealth Day Surgery and Medical Centre. Over 1500 accredited medical specialists support Parkway’s clinical programs in Heart and Vascular, Neuroscience, Oncology, Musculoskeletal, Transplant and Cellular Therapy, Women and Children, Chronic Disease Management and Surgery. Visit www.ParkwayHealth.com or www.parkwayholdings.com

Airlines end girl's trip to China for stem-cell treatment

By Laura Ungar • lungar@courier-journal.com • June 28, 2008

So close in their quest for hope, Miranda Goranflo and her 5-year-old daughter, Hailey, were stopped on the last leg of a trip to Beijing, where the girl was to receive stem-cell treatments for a rare, potentially fatal genetic disease.

Goranflo, of Shepherdsville, said two airlines—Air China and Air Canada—determined Hailey was too sick to fly this week during a layover in Vancouver, British Columbia.

Yesterday, she was being treated for seizures in a Vancouver hospital, and doctors planned to send her to Louisville on a medical flight. Airline officials couldn't be reached for comment.

"I'm completely distraught," said Goranflo, who disagreed that her daughter was unfit to fly. "I cannot believe we've come this far and we have to come home."

Hailey and her 3-year-old brother, Carter, suffer from an incurable disorder called Late Infantile Batten Disease. The disease slowly robs children of their minds and bodies, causing seizures, dementia, blindness, and death between ages 8 and 12. Hailey can no longer walk, talk, or eat without a feeding tube.

Doctors in China offer stem-cell treatments that could help the children -- although some experts say they are potentially dangerous and far less regulated than clinical trials in the United States.

But the family said U.S. trials aren't open to them, so China was their only hope.

They raised about $78,000 for Hailey's trip, and Goranflo's husband, Neil, plans to take Carter to China for treatment in August.

Despite this setback, the Goranflos are still trying to get Hailey to China and have asked U.S. Rep. John Yarmuth, D-3rd District, for help.

Stuart Perelmuter, a Yarmuth spokesman, said his office discovered Hailey needed a waiver signed by a doctor to continue her trip. While her regular doctor in Cincinnati had approved the flight, Perelmuter and Goranflo said Hailey's Vancouver doctor decided not to grant a waiver.

Yarmuth's office plans to help arrange a flight after Hailey returns to Kentucky.

Goranflo said she still hopes her daughter will get the treatment soon.

"I cannot live with the guilt for the rest of my life if I just brought her home and let her die," Goranflo said. "She is still going to China no matter what."

Consultant Offers USB-based PHR

Moore, Oklahoma-based Positive Resource Health Care Industry Consultants, has introduced a portable personal health record product for travelers, individuals with chronic conditions, or in case of emergency. For information on the company and the product, visit http://healthcaretracker.org.

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DESTINATIONS: Adopting a Global Perspective

By Robin Elsham

For years now, the medical tourism industry has been running away from its name. It’s made a cardinal virtue of paying scant attention to the travel aspect of medical travel.

The only real concern shown has been with the risk that medical travelers face from deep vein thrombosis as a result of flying soon after surgery. That concern was almost eagerly acknowledged, as it fit neatly with the image the industry wanted to project—one dedicated to highly principled, conscientious patient care.

To sell magazines, the mass media may feel compelled to portray the industry as equal parts medicine and tourism, the savings on the former more than paying for the latter. Magazine covers picturing a heavily bandaged patient, convalescing on a tropical beach, an intravenous drip stand to one side and barefoot/bare-chested waiter delivering a rum drink to the other, may be the perfect jarring image to spark interest in a cover story entitled "Sand, surf ... surgery!" But it sabotages the message the industry wants to spread: more affordable, high-quality hospital care is available at world-class medical facilities dotted around the world.

The medical travel industry has focused tenaciously on countering the frivolous images conjured up by the term "medical tourism." But in that quest, it's adopted an almost one-eyed view of what's important—strictly the quality and cost of medical care available abroad. Promoting medical travel has calcified into a highly repetitious, two-step sales process: display data showing how much cheaper medical procedures are abroad, then focus all subsequent attention on evidence showing the quality of care is as good, if not often superior.

While understandable, that approach was destined to prove at some point too narrow, too myopic. That point, in fact, has already been reached. Evidence lies all around us. The need for the industry to begin dealing with a messier reality grows more urgent by the day.

The reasons have to do with "peak oil," corn futures at $8 a bushel, the cratering U.S. dollar, currency exchange rate volatility, and highly variable rates of inflation in leading medical travel destinations.

To make sense of this complicated topic, with this issue of Medical Travel Today, this column begins taking a new tact in analyzing destinations. In past months, the focus was on individual destinations, examined one by one, a bottom-up approach. Over coming months, a top-down approach will be taken. Instead of examining how an individual destination measures up as a treatment destination, the focus will shift to global factors now gaining in strength, and weighing unevenly on rival destinations. These factors have the potential to vastly alter the appeal of destinations in as little as three to five years.

That time span is critical because it's the timeframe often adopted for site analysis by group health insurance providers, the most prized customer segment of the medical travel market. When self-insured employers and health insurance companies search for foreign hospitals to include in newly created international service networks, they won't simply be considering the quality and cost of care provided now. A proper SWOT analysis (a full assessment of STRENGTHS, WEAKNESSES, OPPORTUNITIES and THREATS) will also compel an assessment of rival destinations' price competitiveness three, five, 10 years down the road. It’s how key, globally influenced variables might change over time, altering not only the price competitiveness of destinations but demand for entire categories of procedures, that will occupy this column over months to come.

To begin, this series will look at the current tumult in the global airline industry, where the soaring cost of aviation fuel is driving many airlines into the red. In response, many of the world's largest air carriers have recently announced plans to scale back operations. Beginning this autumn, carriers like Air Canada, Qantas, and all seven of the largest U.S. airlines plan to mothball or sell off significant portions of their fleets, slash flights, and pare networks in a bid to regain profitability. For travelers, that means higher ticket prices, more congested aircraft, and probably more convoluted routing options. That's bad news for medical travelers and the medical travel industry alike. But the effects are bound to be uneven. The next column will analyze the likely effects.

Succeeding columns will examine the effects of global inflation and changes in currency exchange rates on the relative appeal of rival destinations. Again, the effects are certain to be highly variable. For example Brazil's currency is up 45% against the U.S. dollar since 2004, dramatically depressing the economic appeal to Americans of traveling there for medical treatment. By contrast, Panama's appeal as a destination only increases as the greenback sinks in value. The reason: the dollar is official currency in Panama, insuring surgery costs there are constant, even while rising elsewhere when paid in dollars.

Ditto for inflation. Prices are rising worldwide, driven everywhere at least in part by many of the same fundamental reasons: the soaring cost of oil and rising food prices. A year ago, among a group of 24 large developing nations tracked by the Bank of America, "about three-quarters were either meeting or staying below their inflation targets. Today none of them are," the Wall Street Journal reported recently.

But inflation rates vary widely by country, as does the ability to contain inflation once it takes root in a nation's economy. Inflation in the United States is currently running at just over 4%, and a little less in Britain. That compares to 7.5% in Singapore, just over 8% in India, and 16.25% in Turkey. Gauging the probability of any foreign treatment destination remaining appealing to American or British medical travelers over years to come must take account of the outlook for inflation in each market. Changes over time will affect the service price difference that's essential to attracting medical value travelers.

As long as the medical tourism industry was focused exclusively on catering to individual medical travelers, simplistic marketing was clearly appropriate. But now that the major market opportunity is serving corporate healthcare plans, simplicity seems more than silly. Destinations that continue to market themselves with that same standard two-step approach—simply citing surgical prices and quality-of-care stats—are going to be out of step with a rapidly maturing, increasingly professionalized market.

Robin Elsham is the managing director of Patients With Passports Corp., an international healthcare arranger based in St. Paul, Minnesota. He can be contacted at robin.elsham@patientswithpassports.com

MEDICAL SPOTLIGHT: Orthopedics

According to reports from the American Academy of Orthopaedic Surgeons (AAOS), musculoskeletal conditions accounted for almost 157 million visits to physicians' offices, 15 million visits to hospital outpatient departments, and 29 million visits to emergency departments. An estimated 150 million work days are lost annually to musculoskeletal injuries and symptoms including pain, ache, soreness, spasms, limitation of movement, stiffness, weakness, swelling, and more.

Increasingly, un- and underinsured Americans, as well as those in need of procedures not yet being performed in the United States, are traveling abroad to access relief for their specific orthopedic conditions. Some American and British patients cite lengthy wait times as the impetus for travel overseas while others seek procedures that aren’t yet offered in their homeland.

Norway, South Africa, Thailand, Panama, and India, in particular, are becoming popular destinations for orthopedic procedures.

According to Kumar Jagadeesan of Starhospitals.net, "India is emerging as being the most economical health destination for orthopedics – particularly for the Medicare age group. Indian hospitals offer significant cost savings on bone and joint treatments and orthopedic surgery procedures such as hip joint replacement, total knee joint replacement (TKR), hip resurfacing, joint revision replacement procedures, arthroscopic procedures, ACL- Anterior cruciate ligament, limb lengthening, fusion procedures, and others."

COST comparison OF ORTHOPEDIC SURGICAL PROCEDURES INDIA

Orthopedic Procedures	Approximate cost Elsewhere - in USD	Approximate cost in INDIA*- in USD
Arthroscopic
Menisectomy	$ 7560	$ 3290
Shaving of cartilage	$ 8400	$ 2750
Ligament Reconstruction - ACL, PCL	$ 18900	$ 3290
Ankle Arthroscopy	$ 9000	$ 2900
Knee Arthroscopy	$ 9900	$ 2900
Elbow Arthroscopy	$ 9900	$ 2900
Shoulder Arthroscopy	$ 9900	$ 2900
Hip Arthroscopy	$ 9900	$ 2900
Tendon Repair	$ 9000	$ 3290
Anterior Cruciate Ligament- ACL	$ 18760	$ 3290
Total Knee Replacement
Knee Joint Replacement Unilateral*	$ 30000	$ 4600
Knee Joint Replacement Bilateral*	$ 54920	$ 7340
Total Hip Replacement
Hip Joint Replacement Unilateral*	$ 30900	$ 5000
Hip Joint Replacement Bilateral*	$ 54900	$ 7700
Illizarov technique
Limb lengthening	$ 19400	$ 5000
Deformity Correction	$ 15960	$ 5390
Problem fractures-Bone Gap, Non-union, Infectious	$ 16800	$ 5600
Fusion
Cervical	$ 27960	$ 6890
Lumbar	$ 30960	$ 8390
Toe - Arthodesis	$ 18400	$ 5000
Sports Injuries
Menisectomy	$ 7560	$ 3290
Shaving of cartilage	$ 8400	$ 2750
Discectomy - Slipped Disc	$ 18600	$ 5300
Polypectomy	$ 9800	$ 3350
Carpal Tunnel Surgery	$ 6800	$ 2600
Birmingham Hip resurfacing	$ 31000	$ 4400
Disc Hernia	$ 34200	$ 7700
Hallux Vagus	$ 9800	$ 2600
Hemi Arthroplasty	$ 9600	$ 3800
Trigger finger correction	$ 3760	$ 2090
Hip Revision*	$ 30400	$ 5000
Knee Revision*	$ 30600	$ 5300
Ankle Replacement*	$ 30900	$ 5300
Arthodesis- Ankle joint Fusion	$ 18000	$ 5900
Finger or Toe Endoprosthesis	$ 14400	$ 5000
Partial Shoulder Endoprosthesis	$ 28800	$ 6800
Total Shoulder Endoprosthesis	$ 36000	$ 8600
Dynesys Surgery	$ 15300	$ 4400
Leg Orthesis-Plain/Large/Carbon Fiber	$ 18000-27600	$4400-6800
Shoulder Tendon Repair -Rotator Cuff	$ 9560	$ 3290
Tendon Repair - Achilles Tendon	$ 9560	$ 3290
Tendon Repair - Extensor	$ 9560	$ 3290
Tendon Repair - Flexor	$ 9560	$ 3290
Fracture - Internal Fixation	$ 9120	$ 2930
Broken Ankle - Open Reduction and Fixation	$ 9280	$ 3290
Bunionectomy	$ 11640	$ 3560
Dupuytrens Contracture	$ 15800	$ 4100
Epidural	$ 9560	$ 3290
Shoulder Replacement	$ 27720	$ 8330
Genu Valgum- Knock Knee Correction	$ 18280	$ 5720
Arthroplasty
Knee Abrasion Arthroplasty	$ 27000	$ 3830
Hip Abrasion Arthroplasty	$ 27900	$ 3980

* Pricing provided courtesy of starhospitals.net. Cost of prosthesis or implant not included.

NOTE: The numbers supplied for the cost of procedures in India include the cost of the procedure plus an additional $1400 USD for roundtrip airfare from New York, NY to Chennai, India. Actual costs and saving may vary depending on the medical travel agency used, patient’s point of departure, need for additional pre- or post-surgical accommodations, additional concierge service fees, and insurance. In some instances, the variance disappears or is diminished when one compares procedure cost in the US to package cost abroad.

According to Dr. Edward Watson of Medtral (http://www.medtral.com), "A significant number of people travel for hip resurfacing, which is only becoming available in the U.S. in certain states, but it has been available abroad for several years."

Citing the most popular orthopedic procedures, Watson includes:

Total hip replacement (arthroplasty)
Total knee replacement (arthroplasty)
Hip resurfacing
Lumbar back surgery

"Hip resurfacing and shoulder resurfacing seem to be gaining popularity as they are less invasive and less traumatic than a total hip replacement (THR). They can be satisfactorily performed on younger patients and allow a delay in the need for a much more invasive THR," says Watson.

Looking toward the future, Watson believes that a holistic approach to orthopedic care is gaining traction.

I feel the centers that provide a holistic approach to the total treatment of orthopedic patients will gain ascendancy as traveling overseas becomes more mainstream," says Watson. A holistic approach, as defined by Watson, would involve the following:

Appropriate patient selection (not all patients should travel for orthopedics)
Appropriate diagnostic work-up before traveling
Appropriate and world-class surgical treatment
Appropriate aftercare, including nursing care post-discharge plus intensive physiotherapy
Appropriate length of stay post-surgery to reduce the incidence of dislocation
Integrated follow-up with physicians in home country (closing the loop)

He adds, "Once the health insurers get on board, traveling for orthopedics will become very much the norm."

Asia’s biggest landmark healthcare congress – GHC 2009—Announces Its Agenda:
How Should Future Models in Healthcare Delivery be Re-Tooled to Handle Disease Management?

The future of healthcare delivery lies mostly in disease-based intervention programs. The healthcare cities and hospitals of the future will greatly benefit from a clearer understanding of how to effectively integrate disease management into future facilities and core competencies to be built.

Another contributing factor that will shape future care models is the growing numbers of high valued patients globally – many of whom are crossing international borders in search of quality care and access. How should hospitals convert their centers of excellence to cater to this growing sector? How can they adequately build capacity and expertise to ensure they are able to meet new and growing demands?