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Medical Tourism - Myth or Reality?

Good Morning, Dr. Christiani and Dr. Herman, thank you for that warm introduction.

Colleagues at the Harvard Medical School Department of Continuing Education, Partners Healthcare, Brigham & Women’s Hospital, Mass General Hospital, physician executives from other institutions – with a special shout out to those who hail from my homeland, Bermuda, friends all –

I am pleased to be here to speak with you this morning. Having been in Boston a time or two in my life, I am particularly pleased that this meeting is being held in June instead of January.

As I looked at the program, I smiled at the theme and its relevance in my own life – “Healthcare Management for Physician Executives”. Now as many of you know, I am a physician and I am an executive – although maybe currently not the type of executive that is at the top of mind in this forum. But, I have a storied past and an even more storied present, where medicine and health care delivery has always been at the top of my mind and patient care at the core of my heart. I believe that whatever we do as health care delivery executives and professionals, whatever our special fields -- whether we are in the operating room or the research lab – our overriding mutual concern will always be our patients.

In my own life, probably the only dark side of leading the country of my birth that I love so much is that I no longer have direct responsibility for patient care. I maintained a private practice in California for 20 years before moving back to Bermuda in 1991 to start Bermuda Health Care Services – the largest healthcare provider in Bermuda outside of the hospital. We have a multi-specialty clinic with 3 full time doctors and visiting sub-specialists on staff and state of the art diagnostic capability, offering MRI’s, mammography, ultrasound, echocardiography and x-rays. Most recently, we branched out and started another clinic – Brown-Darrell (named after my parents) where we currently perform CT studies on a state of the art 64 slice machine, and where we will in the not too distant future offer stem cell transplants.

When I became Premier of Bermuda, I was serving as Medical Director of my clinic and serving my government as Minister of Tourism and Transport. I decided to keep the Tourism and Transport portfolios even after taking over the leadership.

So, you see, I am a busy guy – with a lot of interests in a lot of areas. Today, I want to focus on two of my converged interests – medicine and tourism. I want to spend a few minutes talking about this fairly new term - Medical Tourism.

What is Medical Tourism? It is simply a term initially coined by travel agencies and the mass media to describe the rapidly growing practice of traveling across international borders to obtain health care. So, while it is a new term, it is an old art. All of the pilgrimages we have heard about from biblical times when people traveled hundreds of miles for the lame to be made to walk and the blind to be made to see are grounded on the same premise – people will travel to be healed. Wouldn’t we all?
The most glaring example of this phenomenon is Lourdes, the miracle town in France that is normally populated by 15,000 people but, during the course of a single year, can accommodate 5,000,000 pilgrims from all over the world who are seeking spiritual and physical healing. The tiny town of Lourdes has the 2nd largest number of hotels in France after Paris.
Now, in case we have some skeptics in the house – I want to be clear – we doctors do not think we are God. I am not trying to equate the miracles at Lourdes with the miracles we see in our hospitals. I am simply saying that people will travel to be healed. Healing is the Holy Grail, and people will try to find it wherever it is. That is and will always be.
What we are seeing more of and I want to make a few comments about here is (1) spiraling numbers of Americans who are becoming medical tourists; (2) the establishment of services to support medical tourism; and, (3) carefully proscribed and aggressive attempts to procure medical tourists.

Now, to the first point, why are Americans traveling abroad to seek medical attention? The US health care system represents the best the world has to offer. The annual expenditures exceeds $2.1 trillion, more than $7000.00 for every man, woman and child, which amounts to 16% of the Gross Domestic Product. That figure is projected to exceed 20% in seven years. In total, the US spends more on health care than any other place in the world. So, again, why are Americans traveling abroad?
We all know the answer. Costs. The rising cost of health care in the U.S. is driving the trend.
According to the Kiplinger Report, last year alone, 80,000 Americans traveled abroad for heart surgeries and hip replacement and other medical treatments. Estimates are hard to come by and run as high as 500,000 when they include the many patients who travel for cosmetic and dental surgery, and to clinics just over the Mexican border that specialize in dental implants or lap-band surgery for obesity.
Savings estimates are all over the place as well. One reference states that they can run from 15% to 85%. Many medical tourists are uninsured or have policies that have big co-payments or that will not cover certain treatments. Some travelers have high-deductible insurance policies paired with a Health Savings Account and use their Health Savings Account tax-free to pay for many overseas medical procedures.
At the same time, a growing number of US employers are seeking to cut their health-care costs, and are beginning to encourage their employees to travel abroad for treatment. By way of example, employers that have

contracts with BlueCross BlueShield of South Carolina now offer their employees an overseas option. They also provide their own middleman services through their newly established subsidiary, Companion Global Healthcare, a company specifically devised to arrange for travel, hotel stays and the scheduling of care at hospitals in Turkey, Costa Rica, Thailand and Ireland and other parts of the world. I would venture to say, in the parlance of your US president with whom I was in Washington to meet on Monday, “This medical tourism horse is out of the barn now.”
These middleman services that support medical travelers are typically unattached to insurance companies. They are independently operating travel agencies and professional organizations whose sole business purpose is to facilitate medical tourism. They act as go-betweens -- bringing together the prospective patient with the service provider, usually a hospital or clinic. The most reputable organizations actually match patients with facilities and provide evidence of treatment practices, assessment of physical plants, credentials of health care staff and the like. They provide non-medical information, bridge language gaps, handle ticketing and visa issues, give advice on hotel accommodations and medical risk. Many of them specialize in certain geographical areas and medical procedures.
A new trade group of global hospitals and medical care providers has been formed – the Medical Tourism Association, ostensibly working to bring order to the rapidly expanding universe of global medical care in an attempt to make Medical Tourism appealing not just to the uninsured, but also to employers and health insurance carriers.

They are claiming that US employers and insurance carriers are saving up to 90% of the cost of healthcare expenses by implementing medical tourism. For the first time this year, a Medical Tourism convention will be held in San Francisco.
Meanwhile, countries are capitalizing on the Medical Tourism trend.
According to National Public Radio, increasingly large numbers of patients are traveling farther and farther to seek healthcare – to hospitals in Costa Rica, Thailand and India – for hip joint resurfacing, kidney transplants and prostrate surgery. By their account, no institution serves more foreign patients than a hospital in Bangkok, which is why you hear Thailand in all of these references – can you believe that? Bangkok -- where 450,000 medical tourists from all over the world are treated. NPR goes on to quote a medical tourism consultant who works with the Bangkok hospital and other institutions throughout Asia, in saying that the appeal is simple. It’s about value – great quality, immediate service…service that you’d never find in an American hospital. It’s about price – this time estimated to be anywhere from ½ to 1/8 the cost of health care in the US. And it’s about access – you can see a doctor when you want to see a doctor. There is no issue of waiting.
Many other international hospitals and destinations are realizing the financial incentives associated with attracting international patients. A case in point is Costa Rica, where medical tourism is coined as “the great opportunity”.

The aim is to provide medical services to 0.5% of Americans without medical insurance, currently 230,000 patients. Costa Rica markets itself based on its location, the qualifications of its doctors and 40-70% less cost for surgeries than in North America. Customer service is also emphasized. Personalized care is provided from the airport to the hospital and back again. Vacation time is even planned for family and friends of the patient.

In the Asian market, everything is done for the patient from the time the appointment is made to the time the patient flies back home. International patients receive round-trip airport transportation and reduced rates for accommodation at hotels. Staff guide patients through the admissions process and supply concierge services such as porters, mail, postage and delivery and business center services. The hotels have specially designed programs that include daily transfer, special dietary offerings and free local phone calls to doctors. Language is not an issue – those barriers are broken in this new global health paradigm.
The list goes on. Popular cosmetic surgery destinations include Argentina, Bolivia, Brazil, Mexico and Turkey.
At the top of the medical destinations, one would find India carving out a name for itself in complicated heart surgeries and procedures. Singapore is busy establishing itself as a leading medical destination. Add Brunei, Cuba, Columbia, Hong Kong, Hungary, Jordan, Lithuania, Malaysia, the Phillipines and South Africa …to name a few.

Did I say the horse is out of the barn? It may be on its way to Louisville for the Kentucky Derby. With all of this activity in the area of Medical Tourism, there are many things which I will not discuss today? Importantly, what does this mean for US health care providers such as many of you? There are many risks, and many legal and ethical issues involved with Medical Tourism. But I want to be invited back, so I have to save a few things.
I also want to extend an invitation to all of you to come to Bermuda. In great numbers, Bermudians are medical tourists in America. We have a vast network of service providers who provide us with the best medical services you have to offer – present company is definitely not excluded.
At my medical clinic, Bermuda Health Care, we started a relationship with the Lahey Clinic in 1996. I was determined that ours would be a two-way street. We would send our patients to the US for tertiary care. And highly trained specialists would be sent to Bermuda to treat, and follow-up on, our patients at home. There is an obvious advantage to one doctor traveling to see 30 patients versus 30 patients traveling to see one doctor. We like that advantage, and it has worked to the benefit of Bermudians and the Lahey Clinic.
And, that is the note on which I want to end -- a two-way street, or should I say runway. I am putting back on my Premier hat and welcoming you all to join me in the near future in Bermuda.

Think of us when you are planning your next holiday or your next health care conference. We are only 2 hours away, and while we are not in the medical tourism business to take care of your hip replacements and tummy tucks, we have some beautiful pink sand beaches, moonlight beams and sunshine rays that will melt your troubles away. Come see us soon AND FEEL THE LOVE. Thank you.

Premier Dr. the Hon. Ewart F. Brown
June 26, 2008

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