Captivating Medical Tourism: Understanding & Underwriting the Risks

Presented by:Alice Epstein, MHA, CPHRM, CPHQ, CPEAKathy MeyersCNA HealthPro

Presentation objectives

1. Understand the impact of medical tourism on U.S. healthcare

2. Explore associated risks related to medical tourism

3. Analyze Captive exposures and considerations

What it is, what it is not

• Medical Tourism is traveling abroad for healthcare services.

• Medical Tourism is not emergency or critical care travels:– While out of country– Expatriate care

• Reasons medical tourists go abroad:– Real or perceived lack of services at home– Limitations imposed by payors or regulatory

agencies, certain specialists and/or procedures– Treatment protocols, equipment, or services– Prolonged waiting periods– Lower costs of care– Personal reasons

AffordableAccessibleAvailableAcceptableAdditionalDefining Medical Tourism, Another Approach, Dr. Prem Jagyasi, Chief Strategic Officer, Medical Tourism Association, Medical Tourism Magazine, # 6, August 2008

Market Growth

• Deloitte– Estimates world market at $60 billion,

growing to $100 billion in 2012– Estimates 750,000 Americans traveled

abroad for medical care in 2007, growing to 9,000,000 in 2012

• McKinsey & Company– Places the current market at 60,000 to

85,000 inpatient medical travelers annually [The numbers are based on those utilizing a medical tourism operator (MTO).]

See Resource slide at end of presentation for source references

Medical Tourism Definitions

Medical travel

The travel portion of the trip. When an individual travels across the border and outside one’s customary environment to seek healthcare services.

Medical tourist

Upon arrival, such individual is called a medical tourist.

Medical tourism

Activities which include utilization of healthcare services by the medical tourist, directly or indirectly, e.g. hospitality, cultural exposure, sightseeing

Medical tourism operator (MTO)

Facilitator and coordinator of medical travel and tourism services on behalf of the medical tourist

Medical Tourism Operators Facilitate…

• Client assessment

• Compilation of all pertinent records

• Recommend/match providers abroad

• Scheduling treatment

• Making all travel arrangements

• Handling payment

• Follow-up care upon return

Sample Medical Tourism Destinationsand Cost Comparisons

Procedure

U.S. insurer’s

cost $

U.S. retail

Cost $India $

Thailand $

Singapore $

Angioplasty25,700 - 37,100

57,200 - 82,700

11,000 13,000 13,000

Heart-valve replacement71,400 - 103,100

159,300 -

230,1009,500 10,500 13,000

Hip replacement18,200 - 26,400

43,800 - 63,200

9,000 12,000 12,000

Hysterectomy9,500 - 13,800

20,400 - 29,500

2,900 4,500 -------

Knee replacement17,600 - 25,400

40,600 - 58,700

8,500 10,000 13,000

Medical Tourism Report to the American College of Surgeons Patient Safety and Quality Improvement Committee Highlights, James A. Unti, MD, FACS, May 9-10, 2008, Adapted from WebMD Health Services – US rates, including at least one day hospitalization; Planet Hospital – International rates, 2007 (rounded to $00)

Other Frequented Destinations:

•Argentina•Canada•China

•Costa Rica•Hungary•Jordan

•South Africa•Taiwan•United Kingdom

•Malaysia•Mexico•Philippines

Select Professional Association PositionsAmerican Medical Association

"We need to address the safety aspect for the patient. But the AMA feels patients should be able to go to the doctor they want where they want…Patients should be informed of their rights and legal recourse prior to agreeing to travel outside the U.S. for medical care.”

AMA GUIDELINES ON MEDICAL TOURISM, 6/20/2008

American College of Surgeons

Advises patients to consider the medical, social, cultural, and legal implications of seeking medical treatment abroad prior to deciding on a venue of care.

“In the event of proven medical liability for injury, viable means for the recovery of damages should be in place. Patients should be aware that many of the means for legal recourse available to citizens in the U.S. are not universally accessible in other countries.”

Committee on Perioperative Care, approved by ACS Board of Regents, 2/2009

Consideration of the following factors:– Variability in training of medical and allied professionals– Differences in the standards to which medical institutions are held– Differences in transparency surrounding patient discussions – interpretation of test results– Accuracy and completeness of medical records– Lack of support networks, should longer-term care be needed– Lack of opportunity for follow-up care by treating physicians and surgeons– Exposure to endemic diseases prevalent in certain countries – Language and cultural barriers may impair communication– Compensation for liability associated with injury may be difficult to obtain

MTO Enterprise:Risk Control Considerations

Concerns focus upon:– Business practices of the MTO

• travel logistics• care logistics

– Marketing, warranties and guarantees– Informed consent by medical traveler– Competency of overseas providers– Medical aspects of traveling– Continuity of care– Health information records

Other: Risk Control Considerations

• Complementary and alternative medicine

• Non FDA-approved treatments/procedures/medications

• Clinical trials

• Treatment of minors

• Efficacy of stem cell treatment

• Ethics

Credentialing and Accreditation

• Medical Practitioner Credentialing

• Healthcare Organization Accreditation

Potential Theories of Recovery:Against medical tourism parties

Aware of no claims to date pursued against MTO

• Acts/omissions of the medical professional representing the MTO who initially clears the client for the overseas care

• Negligent credentialing/vetting

• Informed consent re: quality of care provided

• Other

Source: Medical malpractice overseas: the legal uncertainty surrounding medical tourism, P. Mirrer-Singer, 70-SPG Law and Contemporary Problems 211, Spring 2007

Need for Related Medical TourismInsurance Coverage

The specific risks that U.S. healthcare providers will encounter as a result of their involvement are not understood and have not been tested. – Internally (risk evaluation, captive

funding, policy form, coverage, insurance purchase, among other issues)

– Externally (indemnification requirements, international liability laws, among other issues)

Medical tourism:How this may affect a Captive program

Captive Insurers must consider the adequacy of their programs to address this emerging tourism risk and how their specific operations may experience its impact.

• A Captive owner may develop a medical tourism policy as a supplement to an existing, captive-financed benefits program.

• Healthcare systems and entities have developed medical tourism divisions creating risks that may affect captive programs in various areas.

• Physicians covered by a captive may be engaging in medical tourism activities.

• Independent MTOs must determine the most efficient funding alternative, including captive options.

• Third party health care insurers, such as MCOs, are adding medical tourism as a benefit option approved for reimbursement and may employ a captive to fund the program.

• Medical tourists will be seeking insurance options where coverage may not exist in a health plan.

Medical tourism:How this may impact a Captive program

Major Considerations:

• Pricing and underwriting

• Policy form

• Funding and surplus requirements

• Reinsurance availability

• Managing tourism risk

• Claims handling

• Other

Foreign tourists: criticisms of a major medical tourism destination

Obstacles % of Respondents

Maltreatments, such as over-charging by taxi drivers, lack of manners and ill-informed tourist guides and tour operators, cheating, etc, in many tourist destinations such as Agra, Delhi, Mumbai and Jaipur

63%

Delays at immigration counters due to lack of space and inadequate computerization

90%

Bad condition of roads in tourist destinations 55%

High cost of travel from far away countries, including those in Western Europe, North America, Japan, and Australia

30%

Dual pricing of airfares for foreign nationals and domestic passengers (40.5% higher for foreigners)

30%

Entry fees to monuments and heritage sites were higher for foreigners than Indian nationals

30%

Difficulty in obtaining fast connectivity to certain tourist spots or centers 28%

Dissatisfaction with airport facilities like ambience, toilets, cleanliness, cafeteria, baggage and customs clearance, and security

80-90%

Ministry of Tourism, India, India Tourism in 2005, http://www.incredibleindia.org/india_tourism_05_06.pdf (accessed April 29, 2009)

One Foreign Hospital System’s Quality Pushback to Tourist Concerns

• Most sophisticated sleep laboratories in the world

• Pioneered orthopedic procedures– Illizarov procedure – Birmingham Hip Resurfacing technique

• More than 750,000 major surgeries and 1,000,000 minor surgical procedures including;

– Over 49,000 cardiac surgeries, 98.5% success rate– Over 200,000 angiograms– 16,200 angioplasties– 3,500 mitral balloon valvuoplasities– First heart transplant patient was still alive 7 years after the

operation– Over 9,400 renal transplants– 130 bone marrow transplants performed at high success rates– Over 30 liver transplants (live and cadaver)

• Over 4,000 specialists and super specialists, and 3,000 medical officers spanning 53 clinical departments in patient care

Apollo Hospitals, http://www.apollohospitals.com

One Foreign Hospital System’s Quality Pushback to Tourist Concerns (cont’d.)

• Affiliated with: – National Board of Examination in India, postgraduate

training in 16 medical departments– Royal College of Radiologists, UK, for fellowship

examinations training– Anna University, Chennai, research centre for PhD

programs medical physics and digital signal processing

– Royal College of Physicians Surgeons, Edinburgh, radiology, surgery and trauma care postgraduate training

– American Heart Association, sole international training organisation

– Texas Heart institute– Minneapolis Heart Institute– Mayo Clinic– Cleveland Heart Institute– Johns Hopkins University– TJI-accredited

Apollo Hospitals, http://www.apollohospitals.com

Summary

1. Impact of medical tourism on U.S. healthcarea. Emerging riskb. Undefined impact

2. Associated risks related to medical tourisma. Risk identification is actively occurringb. Risk remains largely unquantifiable to

date

3. Captive exposure and considerationsa. May impact healthcare captive insurers

from different aspectsb. Funding and limits should be afforded

accordingly

Resources• AMA Guidelines on Medical Tourism, 20 Jun 2008, American Medical Association, www.ama-

assn.org/ama1/pub/upload/mm/31/medicaltourism.pdf • Apollo Hospitals, http://www.apollohospitals.com• Defining Medical Tourism, Another Approach, Dr. Prem Jagyasi, Chief Strategic Officer,

Medical Tourism Association, Medical Tourism Magazine, # 6, August 2008• HealthCare Tourism International, Trends in Medical Travel ‐ 2007 Report, Neilesh Patel, Elliot

Steven Mendelsohn, Ravi Raghavan , January 18, 2007, www.healthcaretrip.org/statistics/2007trends.pdf?PHPSESSID=88e0852d7adebe8283441a42a57ba62f

• India Tourism in 2005, Ministry of Tourism, India, http://www.incredibleindia.org/india_tourism_05_06.pdf (accessed April 29, 2009)

• Mapping the market for medical travel, McKinsey & Company, May 2008 http://www.mckinseyquarterly.com/Mapping_the_market_for_travel_2134

• Medical Care Outside the United States, AMA Council on Medical Service Report 1 (A-08), American Medical Association, www.ama-assn.org/ama1/pub/upload/mm/372/a-08cms1.pdf

• Medical malpractice overseas: the legal uncertainty surrounding medical tourism, P. Mirrer-Singer, Law and Contemporary Problems, March 22, 2007, Duke University, School of Law

• Medical Tourism: Consumers in Search of Value, Deloitte Center for Health Solutions, 2008• Medical Tourism: Global Competition in Health Care, National Center for Policy Analysis, RH

Herrick, NCPA Policy Report No. 304, November 2007 www.ncpa.org/pub/st/st304• Medical Tourism Report to the American College of Surgeons Patient Safety and Quality

Improvement Committee, Highlights, James A. Unti, MD, FACS, May 9-10, 2008, Adapted from WebMD Health Services – US rates, including at least one day hospitalization; Planet Hospital – International rates, 2007

• Statement on medical and surgical tourism, Developed by the Committee on Perioperative Care, approved by Board of Regents, American College of Surgeons, 2/2009, http://www.facs.org/fellows_info/statements/st-65.html

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