Transcript Medical Tourism - Bermuda Captive

Captivating Medical Tourism:
Understanding & Underwriting the Risks
Presented by:
Alice Epstein, MHA, CPHRM, CPHQ, CPEA
Kathy Meyers
CNA 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.
Affordable
Accessible
Available
Acceptable
Additional
Defining Medical
Tourism, Another
Approach,
Dr. Prem Jagyasi,
Chief Strategic
Officer, Medical
Tourism Association,
Medical Tourism
Magazine, # 6,
August 2008
• 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
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
Medical
tourist
Medical
tourism
Medical
tourism
operator
(MTO)
The travel portion of the trip. When an
individual travels across the border and
outside one’s customary environment to
seek healthcare services.
Upon arrival, such individual is called a
medical tourist.
Activities which include utilization of
healthcare services by the medical
tourist, directly or indirectly, e.g.
hospitality, cultural exposure,
sightseeing
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 Destinations
and Cost Comparisons
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)
U.S.
insurer’s
cost $
U.S.
retail
Cost $
India $
Thailand
$
Singapore
$
Angioplasty
25,700 37,100
57,200 82,700
11,000
13,000
13,000
Heart-valve
replacement
71,400 103,100
159,300
230,100
9,500
10,500
13,000
Hip replacement
18,200 26,400
43,800 63,200
9,000
12,000
12,000
Hysterectomy
9,500 13,800
20,400 29,500
2,900
4,500
-------
Knee replacement
17,600 25,400
40,600 58,700
8,500
10,000
13,000
Procedure
Other Frequented Destinations:
•Argentina
•Canada
•China
•Costa Rica
•Hungary
•Jordan
•Malaysia
•Mexico
•Philippines
•South Africa
•Taiwan
•United Kingdom
Select Professional Association Positions
American 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 Tourism
Insurance 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.
healthcare
a. Emerging risk
b. Undefined impact
2. Associated risks related to medical tourism
a. Risk identification is actively occurring
b. Risk remains largely unquantifiable to
date
3. Captive exposure and considerations
a. May impact healthcare captive insurers
from different aspects
b. Funding and limits should be afforded
accordingly
Resources
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AMA Guidelines on Medical Tourism, 20 Jun 2008, American Medical Association, www.amaassn.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=88e0852d7adebe8283441a42a5
7ba62f
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. MirrerSinger, 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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