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Medical Tourism

Consumers in Search of Value

Produced by theDeloitte Center forHealth Solutions


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Medical Tourism

Foreword

Medical tourism the process of leaving home for treatments and care abroad or elsewheredomestically is an emerging phenomenon in the health care industry. The Deloitte2008Survey of Health Care Consumers, a nationally representative, online survey of more than 3,000Americans, found that outbound medical tourism is expected to experience explosive growthover the next three to five years. Consider the following:

Healthcare

costsareincreasingateightpercentperyearwellabovetheConsumer

PriceIndex(CPI),thus eating into corporate profits and household disposable income.

Thesafetyandqualityofcareavailableinmanyoffshoresettingsisnolongeranissue:OrganizationsincludingtheJoint

CommissionInternational(JCI)


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andothersareaccreditingthesefacilities. Consumers

arewillingtotraveltoobtaincarethatisbothsafeand

lesscostly.Infact,twoinfivesurveyrespondentssaidtheywouldbe

interestedinpursuingtreatmentabroadifqualitywascomparableandthesavings were 50 percent or more.

By contrast, inbound medical tourism and medical tourism across state lines willcontinue to be an interestingopportunity for specialty hubs with treatments unavailable elsewhere in the world or in a community setting.

This report by the Deloitte Center for Health Solutions, part of Deloitte LLP, examines the growth of medicaltourism: the hot spots for outbound and inbound programs, and factors importantto the attractiveness of both.

Medical Tourism: Consumers in Search of Value is Deloittes latest report about innovations that might be

considered disruptive to some in the U.S. health care system. Recent reports spotlighting retail clinics, themedical home payment model and other innovations point to a common theme CHANGE.


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Thevaluepropositionina

consumertransactionusuallyinvolvesconsiderationaboutprice,qualityandservice.Distinctsegments

ofthemarketvaluethethreedifferentlybasedontheirneedsandwants.

Inhealth

care, price hasnt been a factor to many since consumer out-of-pocket expendituresare only 19 percent ofthe total. However, that percentage is increasing and price sensitivity is soaring, especially for those withhigh-deductible insurance programs. The growth of medical tourism might be a signal as to how consumers

calculatetheirvaluepropositionweighingallthreeprice,qualityandservice.Timewill

tell.


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Paul H. Keckley, Ph.D.Executive DirectorDeloitte Center for Health Solutions


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Medical Tourism

Traveling for Care

Many patients are traveling great distances to obtain medical care.Whether the destination is an exotic resort halfway around the

world or a health care facility several hours away in a neighboringstate, U.S. citizens are increasingly embracing the benefits of medicaltourism. Rapid expansion of facilities for patients abroad has helpedto spur this industry growth.

Broadly speaking, medical tourism is the act of traveling to obtainmedical care. As described in Figure 1, there are three categories ofmedical tourism: outbound, inbound and intrabound (domestic).

Figure 1: Types of Medical Tourism

Outbound U.S. patients traveling to other countries to receive

medical careInbound PatientsfromothercountriestravelingtotheU.S.to receive medical careIntrabound* U.S. patients traveling within the U.S. to receivemedical care outside their geographic area,typically to a Center of Excellence in another

state/region

*Data are inconclusive to quantify the intrabound market, so thispaper will focus primarily on outbound and inbound medical tourism.

Note: Definition for the study based on review of articles inAppendix I.

2008 Deloitte Development LLC. All rights reserved.

OutboundMedicalTourism

In 2007, an estimated 750,000 Americans traveled abroad for medicalcare. As depicted in Figures 2 and 3, this number is estimated toincrease to six million by 2010.1,2 Accordingly, the base-case estimatefor the annual growth rate in outbound medical tourism is estimatedat 100 percent from 2007 to 2010. Increases beyond this time,however, could be tempered by several factors:

Supplycapacity

constraintsinforeign


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countriesU.S.healthplanspossibledecision

tonotcoverservicesprovidedoffshore

U.S.providerspossibledecision

tocompetemoreaggressivelywith outbound programs

Potentialgovernmentpoliciesthatmightcurtail

demand.Figure 2: U.S. Outbound Patient Flow, 10-Year Projection (millions)

25

20

15

10

5

-

2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017

Upper Bound

Base Model

Lower Bound

Assumptions

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1 Baliga H. Medical tourism is the new wave of outsourcing from India, India Daily, Dec 23, 2006. Available at: www.indiadaily.com/editorial/14858.asp

2 Horowitz MD and Rosensweig JA.Medical Tourism

Health Care in the Global Economy, The Physician Executive, Nov/Dec 2007


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Medical Tourism

Figure 3: Patient Demand, Outbound Tourism

Year 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017Base

CasePatients(millions)0.75 1.50 3.00 6.00 7.50 9.38 10.78 12.39 13.64 15.00 15.75GrowthRate %100 100 100 25 25 15 15 10 10 5LowerBoundPatients(millions)0.75 1.50 3.00 5.25 6.56 7.55 8.68 9.55 10.02 10.32 10.43

GrowthRate %100 100 75 25 15 15 10 5 3 1UpperBoundPatients(millions)0.75 1.69 3.38 6.75 10.13 12.66 15.19 17.47 20.09 22.09 23.20GrowthRate %125 100 100 50 25 20 15 15 10 5

Assumptions

In2007,approximately750,000Americanstraveledoutboundformedicalcare.Thatnumberwillincreasetosixmillionby2010.3,4Therefore,thegrowthrate

from2007to


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2010is100percentforthebase

caseestimate.After2010,thegrowthratewillbegintofall

duetosupplycapacityconstraintsinforeigncountries.Upper/Lowerboundestimatesassume

thegrowthrateishigher/lowerthanthebasecaseestimate,asshowninthetable. 2008 Deloitte Development LLC. All rights reserved.

ATimelyOptionfor

U.S. ConsumersThe impact of dramatically rising U.S. health care costs is felt in every

household and by every company. Even consumers with employer-sponsored health insurance are increasingly considering outboundmedical tourism as a viable care option: As their plan deductibles


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increase, many of the services available in outbound settings may bepurchased under the deductible limit, thus conserving their HealthSavings Account (HSA) balance.

Medical care in countries such as India, Thailand and Singapore can costas little as 10 percent of the cost of comparable care in the United States.The price is remarkably lower for a variety of services, and often includes

airfare and a stay in a resort hotel. Thanks, in part, to these low-cost carealternatives which almost resemble a mini-vacation, interest in medicaltourism is strong and positive.

IncreasedConsumerismFuelingOutboundTrend

Health care consumerism is premised on the idea that individuals

should have greater control over decisions that affect their healthand their medical care. Employers, health plans and policy-makersrecognize that unless consumers are more engaged in decisions abouttheir health and the costs associated with those decisions, costs willcontinue to soar. HSAs, high-deductible plans, and higher co-paysare prompting patients to act more like consumers. In addition toproviding incentives for patients to take a more active role in their care,many health plans provide resources to help facilitate patient decisionmaking. Furthermore, the Internet has become a significant source ofinformation for patients who want to learn more about their medicalconditions, diagnostic results, and treatment options.

3 Baliga H. Medical tourism is the new wave of outsourcing from India, India Daily

, Dec 23, 2006. Available at: www.indiadaily.com/editorial/14858.asp4 Horowitz MD and Rosensweig JA. Medical Tourism Health Care in the Global Economy, The Physician Executive, Nov/Dec 2007


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Medical Tourism

As patients are exposed to greater financial burdens resulting fromhigher co-payments and price transparency efforts, they are likely toseek low-cost treatment alternatives such as medical tourism. TheDeloitte 2008 Survey of U.S. Health Care Consumers revealed strong

interest in outbound medical tourism. The survey also found that

respondentswerentoverlyconcernedaboutqualityandsafety,as

illustrated in Figure 4.5

Figure 4: Consumer Interest in Outbound Medical TourismAlmost 39% say they would go abroad for an elective procedure if they could savehalf the cost and be assured quality was comparableWould consider having an elective procedure in a foreigncountry if I could save 50% or more and be assured thequality was equal or better than in the U.S.Travel outside my community for treatmentMay travel outside my community for treatmentMay travel outside the U.S. for treatment 2008 Deloitte Development LLC. All rights reserved.

U.S. health care consumers may be ready to vote with their feet if they cannot get high-quality outcome assurances atreasonable costs locally. While only 12% have traveled outside their community fortreatment and only 3% havetraveled outside the U.S. for treatment, many more said they may do so in the future.Consumers who rate their health in the top 20% are more likely than others to considertraveling out of their communities for better care.Source: Q 25. Which of the following have you done in the last 24 months? Whichof the following seem likesomething you might do in the future?Q 26. Would you consider going out of your community or local area to get care/treatmentfor a condition if you knew the outcomes were better and the costs were no higher there?Q 27. Would you consider having an elective procedure like hip replacement or cosmetic surgery in a foreign countryif you could save 50% or more and be assured the quality was equal or better than what you can have in the U.S.?Traveled outside the U.S. for treatmentWould consider going out of my community or local areas toget care/treatment for a condition if I knew the outcomeswere better and the costs were no higher there27%

3%38%12%


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39%88%Gen Y% would consider having electiveprocedure in foreign countryGen XBoomers

SeniorsMaleFemaleHispanicNon-HispanicCaucasianAfrican AmericanAsianOtherHealth Status Top 20%Health Status Bottom 50%Commercial Insurance

MedicareMedicaidOther Insurance36.7%29.1%44.5%33.3%51.4%36.9%37.9%36.9%56.8%43.7%

40.1%33.6%40.6%28.0%29.9%35.4%51.1%41.9%5 http://www.deloitte.com/dtt/article/0%2C1002%2Ccid%25253D192707%2C00.html


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Medical Tourism6Successful Positioning ofMedical Tourism ProgramsWhile medical travel to countries outside the United States has existed foryears, its growth potential was hindered by capacity and infrastructure

constraints among them, communications, transportation, waterand sewer, electricity and power generation in developing nations.However, strong economic development in these countries has providedthe resources and opportunities to build massive health care centers forpatients traveling from all around the world. Some examples: The Department of Health in the Philippines has produced a medicaltourism guidebook that will be distributed throughout Europe. The Korean medical tourism promotion policy has led to theplanning of new medical institutions for international patients. In Taiwan, the government has announced a $318 million projectto help further develop the countrys medical services. In Malaysia, the government has increased the allowed stay under

a medical visa from 30 days to six months. The government of Singapore has formed a collaboration ofindustry and governmental representatives to create a medicalhub in Singapore.In fact, hot spots for medical tourism are prominent around theglobe. At least 10 regions now host medical tourism hubs, asdepicted in Figure 5:Definition: Medical TourismMedical tourism refers to theact of traveling to anothercountry to seek specializedor economical medical care,well being and recuperation

of acceptable quality with thehelp of a support systemMarket Drivers forMedical Tourism Cost savings Comparable or betterquality care Shorter waiting periods,thus quicker access to careGlobal Market forMedical Tourism World medical tourismmarket is estimated to bearound $60 billion currently;it is expected to growto $100 billion by 2010(estimates vary) Over 500,000 Americanstraveled abroad for medicalprocedures in 2005 Over 35 countries areserving around a million+medical tourists annuallyFigure 5: Medical Tourism and Medical TravelingBrazil

Cost: 40%-50% of U.S. Proximity makes itattractive for U.S.


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patients Reliable cosmeticsurgeries 12 JCI accreditationsSouth Africa Cost: 30% to 40%of U.S.

Suitable for cosmeticsurgery No JCI accreditationMalaysia 300,000 tourists in 2006 Cost: Avg. 25% of U.S. Mainly cosmeticsurgery and alternativemedicine 1 JCI accreditationSingapore 410,000 tourists in 2006Cost: Avg. 35% of U.S. 13 JCI accreditations

India 450,000 tourists in 2007 Cost: Avg. 20% of U.S. 10 JCI accreditationsMexico Cost: 25%-35%of U.S. High volume ofU.S. visitors due toproximity Mainly dental andcosmetic surgery

3 JCI accreditationGulf States Healthcare Citydesigned to provideadvanced healthcareservices 38 JCI accreditationstotal; with 17 inSaudi Arabia Thailand 1.2 million touristsin 2006 Cost: Avg. 30% of U.S. 4 JCI accreditations 2008 Deloitte Development LLC. All rights reserved.Note: JCI accreditation details at www.jointcommissioninternational.org/23218/iortiz/.Other sources and explanation appear in Appendix II.Hungary Cost: 40%-50% of U.S. Mainly used byEuropeans Reliable dental andcosmetic surgery No JCI accreditationCosta Rica

Cost: 30%-40% of U.S. Mainly dental andcosmetic due to


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proximity to U.S. 1 JCI accreditation


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Figure 7: Safety, Quality and Accreditation Issues Needed to be Asked by the ConsumerKinds of Accreditation Details to be VerifiedWhy is it important?Helpsconsumersselectaproviderbasedonmaintenanceofcertainstandards,medicalethicsandquality.

What does it involve?It measures certain parameters like:Medicalpractitionershavingrequiredtrainingalongwithpassingthe qualified exams Robustfacilitiestohandleinpatientandoutpatientcare Coordinationcapabilitieswithdifferentagencieslikeinsuranceproviders,governmentagenciesandotherfacilitators Acceptablemedicalratios:patienttodifferentkindofmedicalstaff ratios Culturalsensitivityandunderstandingofinternationaldiversity 2008 Deloitte Development LLC. All rights reserved. JCI:JointCommissionInternational ISQUA:TheInternationalSocietyforQualityinHealthCareHospitalOtherBodies TrentAccreditationScheme(UK) QualityHealthNewZealand NetherlandsInstituteforAccreditationofHospitals Councilfor

HealthServiceAccreditationofSouthernAfricaQualityNCQA:NationalCommitteeforQualityAssurance ISO:InternationalOrganizationforStandardization ESQH:EuropeanSocietyfor

QualityinHealthcareNote: Insights drawn from:articlesfromhttp://www.healism.com/Medical_Tourism_Safety/ and http://www.healism.com/FAQs/FAQs_About_Travel/Medical_Tourism_FAQs_About_Travel/Accreditation:TheFacts,IMTJ (International Medical Travel Journal),June18,2007Kindsof Accreditation Details to be VerifiedWhy is it important?Helpsconsumersselectaproviderbasedonmaintenanceofcertainstandards,medicalethicsandquality.What does it involve?It measures certain parameters like:

Medicalpractitionershavingrequiredtrainingalongwithpassingthe qualified exams Robustfacilitiestohandleinpatientandoutpatientcare Coordinationcapabilitieswithdifferentagencieslikeinsuranceproviders,governmentagenciesandotherfacilitators Acceptablemedicalratios:patienttodifferentkindofmedicalstaff ratios Culturalsensitivityandunderstandingofinternationaldiversity 2008 Deloitte Development LLC. All rights reserved. JCI:JointCommissionInternational ISQUA:TheInternationalSocietyforQualityinHealthCareHospitalOtherBodies TrentAccreditationScheme(UK) QualityHealthNewZealand NetherlandsInstituteforAccreditationofHospitals CouncilforHealthServiceAccreditationofSouthernAfricaQuality NCQA:NationalCommitteeforQualityAssurance ISO:InternationalOrganizationforStandardization ESQH:EuropeanSocietyforQualityinHealthcareNote: Insights drawn from:articlesfromhttp://www.healism.com/Medical_Tourism_Safety/ and http://www.healism.com/FAQs/FAQs_About_Travel/Medical_Tourism_FAQs_About_Travel/Accreditation:TheFacts,IMTJ (International Medical Travel Journal),June18,2007Medical Tourism

Malpractice/LiabilityQuestions

Isa


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propercontractofservicesmade?Doesit

makeanypartyaccountableincaseofcomplicationduetonegligence?Historically,

whathasbeenhospitalstrackrecordindealingwithmalpracticeclaims?Doesany

payorcoverthecostofsuchmedicalprocedures?Ifyes,whatarethetermsandconditions?Whatarethelocalregulationstodealwithmalpractice

issuesandhow


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dotheydifferfromthoseinthe

UnitedStates?Isthereanygovernment/non-profitorganizationtohelpthemwithlegal

assistanceandadviceincaseofmalpractice?

Safety Issues Questions

Aretheaccreditationsregularlyrenewed?Isthehospitalfollowingallthestandardsafetynorms?Arethedisposablesbeingtakencareofproperly?

Arethefood


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andinpatientfacilitieshygienic?Isstafffluent

inEnglishorisinterpretercompetenttopreventanymiscommunication?Howsafe

andsecureistheenvironmentattheprovidersite?Whataretheprecautions

tobetakenforthepost-proceduralcare?

Quality: A Primary Consideration

Increased access to report cards about provider safety and effectiveness,and patient satisfaction scores for hospitals and physicians have helped

tofuelgrowingconsumerandemployerawarenessofsafetyandquality

differences. Traditionally, academic medical centers (AMCs) have been


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viewed as the best, but these data reflect comparable performancein community-based settings for certain services. AMCs have developedhighly specialized Centers of Excellence programs to attract patientsfrom around the world. Not to be outdone, community-based hospitalshave collaborated with their physicians to develop centers for sportsmedicine, heart care, cancer care, and other specialties to compete forpatients across state lines and national borders. In both cases, strategic

positioninghasfocusedoncontinuityofcareanduniquelypackagedprice,

qualityandservicefeatures.

Receivingsafeandqualitycareisthe

primaryissueforconsumers

considering outbound medical tourism as a treatment option. Outbound

medicaltourismsponsorsarerespondingtoconsumerssafetyandqualityexpectations,andtypicallytouttheseprogramattributes:


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U.S.-trainedphysiciansandcareteamsUse

ofclinicalinformationtechnologiesUseofevidence-basedclinicalguidelinesAffiliations

withreputable,top-tierU.S.providerorganizationsCoordinationofpre-andpost-dischargecare

ProvisionforadverseeventsrequiringservicesunavailableinthefacilityCertificationforsafetyandqualitybytheJointCommissionInternational or others.

The Joint Commission International (JCI) was launched by the JointCommission in 1999 after a growing demand for a resource to effectively

evaluatequalityand


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safety.Thereareover120hospitalsworldwide

that

are accredited through the JCI.6 Several other organizations, such as theInternational Society for Quality in Health Care (ISQUA), the NationalCommittee for Quality Assurance (NCQA), the International Organizationfor Standardization (ISO), and the European Society for Quality inHealthcare (ESQH), have taken steps to ensure that medical tourism

facilitiesprovidethe

highest-qualityclinicalcare(Figure7).

6 https://www.healthbase.com/hb/pages/hospitals.jsp


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Medical Tourism

Accreditation is particularly important because it can give consumers andemployers a level of confidence that the services provided are comparableto those available in the U.S., particularly if accompanied by an affiliationwith a reputable, U.S. teaching hospital (Figure 9). As a result, many well-

known AMCs have formed international partnerships to support offshoretourism ventures and provide a variety of services, such as:

ClinicalguidelinesandordersetsCareplans

forpatientstofacilitateself-careandadherenceElectronicmedicalrecordsandclinical

informationtechnologiesOutcomemeasurementandreportingRoot-causeanalysisforsentineleventsanderrorreportingPhysicianandnurserecruitmentandtrainingPatient

satisfactionsurveysand


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reportingMedicalandprofessionaleducation

PurchasingprogramsfordiagnosticsandprescriptiondrugsDatawarehousingandperformance

reporting.The legal frameworks used in collaborations between U.S.-basedprovider organizations and host outbound medical tourism programsvary widely. Some focus on work-for-hire for some/all of the services

above;othersareequityrelationships.Theframeworkin

Figure8

reflects the variety of structures that might be considered.

Figure 8: Collaboration Framework Options and ConsiderationsSharelessonslearnedCo-brandedhospitalFacilitiesplanningServicetrainingTertiaryCareHospitalsSecondaryCareHospitalsPrimaryCareHospitalsDifferent types ofactivities done byU.S.-basedprovidersto ensure global playBranding,Advisory&SharedServicesTraining&ConsultingServicesInfrastructure&MedicalServicesAMC/MedicalResearchSetUpofCollaborationCategory/LevelofInvolvementTacticalPartnerships Developpartnershipsopportunistically with industryplayers when approached forclinical expertiseLimitedfocusoncollaborationand not considered as a majorrevenue streamStrategicPartnerships Long-terminvolvementwithindustry partnersHigherfinancialinvestmentswithlong-termrevenuesin mind

StrategicBusinessInitiatives Creationofaseperateinitiativeto proactively develop andmanage collaborations


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Humanandfinancialresourceinvestments with profit motivesHighHighLowLowMedical researchVirtual researchcollaborationKnowledgesharingCOEsMedical school

Fellowships/internshipsCurriculumdevelopment 2008 Deloitte Development LLC. All rights reserved.Level of InvestmentNote: Insights are drawn from review of articles in Appendix I.Drivers for venturinginto InternationalOperations Pressureduetofallingprofit margins as aresult of high numberof domestic managed

care patients Potentialofdoinghigh-valuemedicalprocedures


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Medical Tourism10Figure 9 lists U.S. health care organizations that are involved in someof the better-known international collaborations.Figure 9: Outbound patients from U.S. have an option to travel to U.S. providers(at international sites) or their affiliates and partners

Enablers Large uninsured population Growth of the travel industrymakes it easier to travel Communication improvementsallow patients to be in touchwith providers much earlier,thus enabling dialogueInhibitors Patients personal concerns Logistics-related issues Lack of clinical support systems for

continuity of care once back in thecountry of origin Safety concerns and litigation rules inrelation to failed medical interventionGrowth Boosters Out-of-pocket expenses: 18% of250M insured Americans, not qualifiedfor certain procedures, which results inhuge out-of-pocket expenses Uninsured: 47M uninsured Americans Cost-cutting: Health plans andCompanies are seeking ways toreduce costs

U.S. providers B/T/C HS MS TotalCleveland Clinic 2 2Cornell MedicalSchool 1 1Duke MedicalSchool 1 1Harvard MedicalInternational 23 23Johns HopkinsInternational 11 1 12Memorial SloanKettering 9 9University ofPittsburgh 3 3Columbia UniversityMedical School 3 1 4Note: This is an indicative list (for illustrative purpose) 2008 Deloitte Development LLC. All rights reserved. HS Hospital Service MS Medical School B/T/C Branding/Training/ConsultingCountry with U.S. provider footprint/tie-upNote: Insights are drawn from articles and web sites in Appendix III.


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Medical Tourism

Care coordination for patients returning home is another dimension of

qualitythat

iscentraltoahostorganizationsperformance.ManyU.S.

based opponents to medical tourism worry that patients who receive

treatment abroad do not receive proper follow-up care when they returnto their home country. As a result, care plans that facilitate the handoff

fromoverseasproviderstoprovidersatthepatientshomeare

critical,

since domestic providers are often hesitant to take on complicated andopen cases from unknown providers let alone care from a foreign one.

Afinalissuerelatedtoqualityisliability.Althoughmedicaltourism

offers significant cost savings, it comes with increased risk toconsumers.7 If anything were to go wrong during a procedure in a

foreigncountry,the

consumerhasto


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workthroughthehostcountrys

legal system. This can be difficult and burdensome if the consumer

lives far away from the place s/he received treatment. Additionally,many of the larger health insurance providers have not yet embracedmedical tourism because they are worried about potential lawsuitslinked to bad outcomes.8 As medical tourism increases, insurers mustfind ways to cope with consumers who look to them for liability.

Facilitating Seamless Coordination

ofOutbound

Programs

The decision-making process for patients considering treatment abroadcan be daunting. Figure 10 reflects the typical decisions and actionsthat take place.

Figure 10: Pre- and Post-procedure Decision-making ProcessSourceofinformationPost-operativecareFollow-upcareFacilitatorFinalizelogisticsandcourseofactionDuesclearanceand return tohome

Monitoring forcomplicationsPhysicaltherapyand progresscheckFollow-upcareand medicineinstructionsPost-treatmentleisure (if desiredby patient)Fillforms,discuss paymentdetailsProvideconditionbackground,test resultsMedicalTourismOperator(outsourced byprovider)Internationalcenter of theproviderDirect referralsfrom providerWordofmouth/personal contactsMedia/InternetPersonalizedcoordinator

takes chargePatientreacheshospital sitePre-medicalcheck-upProcedureconducted


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Follow-upcarebytheU.S.basedproviderandsupport in case of anycomplicationPost-procedurePre-procedureMedicaltraveler in needof medicalinterventionFinalizetravelitinerary,lodging,

visa/passportDiscuss course ofmedical action (atlocal branch orthrough Internet)Note: Insights drawn from various providers treating international patients; from IMTJ (International Medical Travel Journal) article,FinancialFocus:Paymentoptions,June18,2007;andfromthefollowingwebsites:TajMedicalGroup:http://www.tajmedical.com/e-medSol:http://www.emedsol.biz/MedicalTourismAssociation:http://www.medicaltravelauthority.com/InternationalMedicalTravelAssociation:http://www.intlmta.org/web/imta/home 2008 Deloitte Development LLC. All rights reserved.

7 Van Demark D.How will the medical tourism industry in the United States develop? Consumer Health World, March 2, 2007.

Available online at: http://trusted.md/blog/dale_van_demark/2007/03/02/how_will_the_medical_tourism_industry_in_the_united_states_develop

8 AllenG.Employers,insurersconsideroverseashealthcare,

NPR,November14,2007.Availableonlineat:http://www.npr.org/templates/story/story.php?storyId=16294182


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2008 Deloitte Development LLC. All rights reserved.Figure 11: Medical Tourism Service FacilitatorWhoaretheyCompaniesorcorporationsthatareinthebusinessoffacilitatingmedicaltourismfor both consumers and providersWhyconsumersuseservicefacilitatorsManycentralandstate governmentshave realized

the potential ofmedical tourism forthe local economyPhilippines:TheDepartmentofHealth(DOH)isproducinga medical tourismguidebook that willbe launched in variousEuropean citiesKorea:ThecityofSeoulisplanningtobuild a complex ofmedical institutionsas a result of itsmedical tourismpromotion policy

Taiwan:Govtinvesting$318Mtodevelopmedical servicesMalaysia: Medicalvisa regulation haschanged,increasedtosix months from thecurrent 30 daysSingapore:SingaporeMedicine,amulti-agency composedof governmentand industryrepresentatives,has been formed topromoteSingaporeas a medical hubPolicy-

makersrolein medicaltravelPost-procedurefollow-upquestionsFacilitatorexperience&know-howSavingduetonegotiatedratesAssistancein logisticsand otherarrangementsFull-timeoperatingunitswhosebusinessisdependent on international medical travelExample MedRetreat PlanetHospital GlobalChoiceHealthCare BridgeHealthInternationalMedicalTravelPlannersExample Bumrungrad(Thailand) Apollo(India)ProviderGroupsConvenience:one stopNote: Insights drawn from:(1)Thefollowingwebsites:TajMedicalGroup:http://www.tajmedical.com/e-medSol:http://www.emedsol.biz/MedicalTourismAssociation:http://www.medicaltravelauthority.com/

InternationalMedicalTravelAssociation:http://www.intlmta.org/web/imta/home(2)ITC-Welcomhotelsplansforayintomedicaltourism,http://www.thehindubusinessline.com/2008/02/04/stories/2008020451620100.htm,February3,2008(3) IMTJ (International Medica


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l Travel Journal) articles:IncreasedActivityfromthePhilippines,February2,2008SeoulMayBuildaMedicalTravelComplex,ebruary2,2008TaiwantoHelpPromoteMedicalTravelbyRelaxingVisaRestrictions,June18,2007Malaysia:HealthTouristVisasExtendedto6Months,January20,2008Singapore:TargetingtheMiddleEast,March1,2008AccommodationDuringTreatment:MedicalFacilitiesandHotels,June18,2007MedicalTravelPlanners:Canbeanagencyorrepresentative who aids a patient in finding

medical treatment abroadProviderGroups:Havededicatedclinicalprograms for international patients HotelGroups:Haveexpandedtheirserviceline,wheretheyactasafacilitatorbetweenthe patient and the provider or agencieswhich are associated with hotel groups TravelAgencies:Havetourplansformedicaltravelers for clinical programs and utilize theirlogisticsknow-howasastrengthWhoaretheyCompaniesorcorporationsthatareinthebusinessoffacilitatingmedicaltourism for both consumers and providersWhyconsumersuseservicefacilitatorsManycentralandstate governmentshave realizedthe potential of

medical tourism forthe local economyPhilippines:TheDepartmentofHealth(DOH)isproducinga medical tourismguidebook that willbe launched in variousEuropean citiesKorea:ThecityofSeoulisplanningtobuild a complex ofmedical institutionsas a result of itsmedical tourismpromotion policyTaiwan:Govtinvesting$318Mtodevelopmedical servicesMalaysia: Medical

visa regulation haschanged,increasedtosix months from thecurrent 30 daysSingapore:SingaporeMedicine,amulti-agency composedof governmentand industryrepresentatives,has been formed topromoteSingaporeas a medical hubPolicy-makersrolein medicaltravelPost-procedurefollow-upquestionsFacilitatorexperience&know-howSavingduetonegotiatedratesAssistancein logisticsand otherarrangementsFull-timeoperatingunitswhosebusinessisdependent on international medical travelExample MedRetreat PlanetHospital GlobalChoiceHealthCare BridgeHealthInternational

MedicalTravelPlannersExample Bumrungrad(Thailand)


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Apollo(India)ProviderGroupsConvenience:one stopNote: Insights drawn from:(1)Thefollowingwebsites:TajMedicalGroup:http://www.tajmedical.com/e-medSol:http://www.emedsol.biz/

MedicalTourismAssociation:http://www.medicaltravelauthority.com/InternationalMedicalTravelAssociation:http://www.intlmta.org/web/imta/home(2)ITC-Welcomhotelsplansforayintomedicaltourism,http://www.thehindubusinessline.com/2008/02/04/stories/2008020451620100.htm,February3,2008(3) IMTJ (International Medical Travel Journal) articles:IncreasedActivityfromthePhilippines,February2,2008SeoulMayBuildaMedicalTravelComplex,ebruary2,2008TaiwantoHelpPromoteMedicalTravelbyRelaxingVisaRestrictions,June18,2007Malaysia:HealthTouristVisasExtendedto6Months,January20,2008Singapore:TargetingtheMiddleEast,March1,2008AccommodationDuringTreatment:MedicalFacilitiesandHotels,June18,2007MedicalTravelPlanners:Canbeanagencyorrepresentative who aids a patient in findingmedical treatment abroadProviderGroups:Havededicatedclinicalprograms for international patients HotelGroups:Haveexpandedtheirserviceline,wheretheyactasafacilitatorbetweenthe patient and the provider or agencieswhich are associated with hotel groups TravelAgencies:Havetourplansformedicaltravelers for clinical programs and utilize theirlogisticsknow-howasastrengthMedical Tourism

Independent groups venturing into medicaltourism as a new business opportunity

ExampleITC-WelcomGroupTajMedicalGroup(which has alignedwith various hotelgroups)HotelGroupsExampleCommonwealthTravel(Singapore)TravelAgencies

Because of this complexity, many patients look to their health planor employer to assist in navigating the process. In some cases, theseorganizations hire medical facilitators to seamlessly coordinateoutbound medical tourism programs.

Medical facilitators are companies that guide the use of medicaltourism for patients and providers. Many patients find using facilitatorsto be more convenient and expedient than looking for a program on


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their own. Facilitators have experience in the medical tourism process

andareabletoaddress

anyconcernsorquestionsthatpatients

might have. They often provide assistance with logistics and travel

arrangements.Patients

mayevenbeabletogetlowerratesfrom

medical facilitators than directly from clinical programs abroad.

Medical facilitators can be divided into four groups (Figure 11):

HotelGroups,suchastheITC-WelcomGroupinIndia,haveexpanded their service line to act as facilitator between the patientand the provider.

TravelAgencies,suchasCommonwealthTravelinSingapore,have

tour plans for medical travelers and utilize their experience toorganize logistics.


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MedicalTravelPlanners,suchas

MedRetreat,PlanetHospital,GlobalChoice Healthcare, and BridgeHealth International, act as patientrepresentatives in finding treatment abroad.

ProviderGroups,suchas

BumrungradinThailandandApolloinIndia,have dedicated clinical programs solely for international patients.


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Medical Tourism

Savings Can Be Significant

As illustrated below in Figure 12 and the table, the use of medicaltourism programs can save consumers as much as 90 percent, when

compared to U.S. costs.

Figure 12: Cost Comparison of U.S. vs. Foreign Surgical Procedures9

Americans use outbound medical tourism programs primarily for electivesurgical procedures. Figure 12 displays the estimated price differences

for15surgicalproceduresfrequently

usedinoutboundprograms.

Note that prices vary widely by country, and costs associated with travel

toandfromthesurgical

facilityalongwithrequiredaftercarecan

reduce the price differential appreciably. When extraordinary traveland insurance costs are added, the relative cost advantage for medicaltourism is 28 to 88 percent, depending on the location and procedure.

Procedure U.S. Inpatient Price(U.S.$)U.S. Outpatient Price(U.S.$)Average of 3 Lowest Foreign Pricesincluding Travel Cost (U.S.$)KneeSurgery11,692 4,686 1,398Shoulder Angioplasty 6,720 8,972 2,493Transurethral

ProstateResection4,669 3,737 2,698


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Tubal Ligation 6,407 3,894 1,412Hernia Repair 5,377 3,903 1,819Skin Lesion Excision 7,059 1,919 919Adult Tonsillectomy 3,844 2,185 1,143Hysterectomy 6,542 6,132 2,114Haemorrhoidectomy 5,594 2,354 884Rhinoplasty 5,713 3,866 2,156

Bunionectomy 6,840 2,706 1,682Cataract Extraction 4,067 2,630 1,282Varicose Vein Surgery 7,993 2,685 1,576GlaucomaProcedures4,392 2,593 1,151Tympanoplasty 5,649 3,787 1,427


FIGURE12

Note:U.S.inpatientpriceswerecalculatedbyaddinghospitalpaymentsthroughDRGs,physician

feesthroughCPTcodes,anesthesiachargesbasedontheMedicareClaimsProcessingManuelandCPTcodes,andpharmaceuticalchargesusingMedstat2005dataforcommercial

liveswiththe


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sameprocedures.

U.S.outpatientprices

werecalculatedbyaddinghospitalfeesthroughtheMedicareOutpatientProspectivePayment

Systemdataset,physicianfeesthroughCPTcodes,anesthesiachargesbasedontheMedicare

ClaimsProcessingManuelandCPTcodes,theminimumadjustedco-paymentsreportedbytheCentersforMedicareandMedicaidServices, and pharmaceutical charges using Medstat 2005 data for commercial lives with the same procedures.

Foreign prices were calculated as the average of the three lowest prices and included travel cost. These data were obtained from Vanbreda International, a Belgium-basedemployee benefits consulting and administration firm, who provided data based on

21 foreign countries. These data were assumed to have the same percentage increasein cost due to pharmaceutical charges as U.S. procedures.


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All values are shown in 2008 U.S. dollars. Figures were converted from 2004 to 2008 dollars. Foreign prices were assumed to have the same inflation rate as U.S.prices.

WeightedPrice

ofaProcedureU.S. $10,629Foreign $1,410

Note: The weighted price of a procedure was calculated by multiplying the priceby the proportion

of overall usage. Each of the proportioned prices is then added to total a weighted average price. For

example,aprocedurepricedat$5,000thatcontributedto10percentofall

proceduresinthedatawould

accountfor$500,whileaprocedurepricedat$3,000occurring50percentwouldaccountfor$1,500.


9 Van Demark D. How will the medical tourism industry in the United States develo


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p? Consumer Health World, March 2, 2007.Available online at: http://trusted.md/blog/dale_van_demark/2007/03/02/how_will_the_medical_tourism_industry_in_the_united_states_develop


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Medical Tourism

MarketOpportunity:

Looking Ahead

The following two sets of figures describe the impact of outboundmedical tourism on the U.S. health care system. Figures 13 and 14

showthatoutboundmedicaltourismcurrentlyrepresents

$2.1billion

spent overseas for care. Figures 15 and 16 highlight the opportunity

costofthe$2.1billionspentoverseas

$15.9billioninlostrevenue

Figure 13: Cost Estimate for Spending by Outbound U.S. Medical Tourists

forU.S.healthcareproviders.Theprojectedincreaseinthenumberof

outbound medical tourists from 750,000 in 2007 to 15.75 million in

2017represents


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apotential$30.3to$79.5billionspent

overseasfor

medical care, resulting in a potential opportunity cost to U.S. health

careprovidersof$228.5to$599.5

billion.

Three factors could help to determine whether the lower or upper limitis realized: the volume of outbound medical tourists, U.S. health care

costincreases,andthepriceadvantageenjoyed

byoutboundprograms.

Year 2008 2009 20102011201220132014201520162017BaseCaseSpending(billionsU.S.$)2.14.49.0 13.921.427.634.140.4

45.749.5Lower


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BoundSpending(billionsU.S.$)2.14.47.9

12.115.619.322.9 25.928.0 30.3UpperBoundSpending(billionsU.S.$)2.44.9

10.115.624.137.247.959.270.279.5

Note:Theweighted

priceofaprocedureinaforeigncountrywasmultipliedbytheflowofoutboundU.S.patients.Inflation-adjustedusingarateofthreepercent.



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Figure 14: U.S. Spending Abroad, 10 Years

$80

$75$70$65

$60$55$50$45$40$35$30$25$20$15$10$5

$02008 2009 2010 2011 2012 2013 2014 2015 2016 2017

Upper BoundBase ModelLower BoundNote: The weighted price of a procedure in a foreign country was multiplied bythe flow of outbound U.S. patients.Inflation-adjusted using a rate of three percent.



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Medical Tourism

Figure 15: Lost Domestic Spending in U.S. by Outbound U.S. Medical Tourists

Year 2008 2009 20102011

201220132014201520162017BaseCaseLostSpending(billionsU.S.$)

15.932.8 67.7104.5161.5207.9257.0304.4344.9373.0LowerBoundLostSpending

(billionsU.S.$)15.932.8 59.291.5117.8145.5172.4195.3211.2228.5UpperBoundLostSpending(billionsU.S.$)17.936.9 76.1117.6181.7280.7361.4446.7529.1

599.5


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Note:Theweightedpriceofaprocedure

intheU.S.wasmultipliedbytheflowofoutboundU.S.patients.

Inflation-adjustedusingarateofthreepercent.


Figure 16: Lost U.S. Domestic Spending, 10 Year Projection (billion U.S.$)

$600$500$400$300$200$100$02008 2009 2010 2011 2012 2013 2014 2015 2016 2017

Upper Bound

Base Model

Lower Bound

Note: The weighted price of a procedure in the U.S. was multiplied by the flow ofoutbound U.S. patients. Inflation-adjusted using a rate of three percent.



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Medical Tourism

Leading U.S.-based Partnerships for Outbound Tourism

University of PittsburghMedical Center

Offers integrated health care delivery system& health plansDescription Employeestrength:43,000employeesNumberofpatients:More

than3millionoutpatientvisits&morethan167,000inpatientvisitsKey focus area(international)

ResearchandeducationforallspecialtymedicalcarePartners/membersHaspartneredwithItalysregionofSicilytodevelopahospitalinPalermo;also

hasamedical center in Qatar and a cancer center at Dublin


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Harvard MedicineThird-oldest medical school in the U.S.Its not-for-profit subsidiary focuses oninternational operationsDescriptionEmployee

strength:10,458facultymembersinclinicaldepartmentsofaffiliatedhospitalsand institutions with a total of over 3,000 beds

Numberofpatients:Offersservicestoover2millionpeopleintheBoston

regionKey focus area(international) Allspecialties;training,medicalconsulting,infrastructureplanningPartners/membersHasdevelopedmorethan50programsinover30countriesacrossfive

continentsDubai


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HealthcareCityislaunchingUniversityHospital,a

400-bedtertiarycareteachinghospitalMemorial Sloan-KetteringCancer Center Description Employeestrength:9,000employees

Numberofpatients:About21,000inpatientsandmorethan431,000outpatientvisitsannually

OneoftheworldspremiercancercentersKey focus area(international) AdvisoryservicesforawidespectrumofcancersPartners/membersHasestablishedrelationshipswithinstitutions

aroundtheworld:


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HongKong,Barcelona,Geneva,Athens,SaoPaulo,

Seoul,Istanbul,SingaporeandPhilippinesCornell Medical SchoolWeill Medical College of Cornell Universitywas founded in 1898; affiliated in 1927DescriptionEmployeestrength:

240full-time,265voluntaryand775networkfacultymembersNumberofpatients:

Nearly2millionpatientvisitsperyear,includingmorethan230,000visitstoitsemergencydepartments(NewYork-PresbyterianHospital)withNewYork-PresbyterianHospitalKey focus area(international)

Researchandeducation,


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withallspecialtymedicalcarePartners/members

HasopenedamedicalschoolinQatarandaresearchand

advisoryinstituteinSeoulMaintainsaffiliationswithMemorialSloan-KetteringCancerCenter,Hospital

forSpecialSurgery and many other metropolitan-area institutionsDuke MedicineIntegrates the Duke University Health System,the Duke University School of Medicine, andthe Duke University School of NursingDescription Employeestrength:8,648employeesNumberofpatients:Morethan1.4millionoutpatientvisits&morethan

60,000inpatientvisits


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Key focus area(international) Education,training,biomedicalresearchPartners/

members HaspartneredwithNUStoopenDuke-NUSMedicalGraduateSchoolSingapore


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Medical Tourism

Leading U.S.-Based Partnerships for Outbound Tourism (cont.)

Johns Hopkins HospitalTeaching hospital in Maryland founded by

Johns HopkinsDescription Employeestrength:25,000Numberofpatients:60,000admissionseach

yearandmorethan500,000outpatientvisitsKey focus area(international)Collaborativeresearch,education,

trainingforphysiciansandothertechnicalstaff,policyplanning, medical servicesPartners/membersHastieswithreputedinstitutesinJapan,Singapore,India,UAE,Canada,Lebanon,Turkey,

Ireland,Portugal,Chile


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andPanamaCityCleveland ClinicOne of the largest health centers in America.It integrates clinical and hospital care withDescription

Employeestrength:Over1,400physiciansNumberofpatients:3millionoutpatientsand

68,000surgicalcasesayearresearch and education Key focus area(international) Allspecialties;clinics,preventivehealthprogram

andwellnessPartners/membersClevelandClinicAbuDhabiinpartnershipwithgovernmentofUAEisscheduledtobeoperational in 2010Hasopenedsatellitecampus

inCanadaColumbia University


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Medical CenterHasfourschools:CollegeofPhysicians

& Surgeons, College of Dental Medicine,School of Nursing, and Mailman School ofPublicHealthDescription Employeestrength:2712fulltimefaculty

Numberofpatients:NAKey focus area(international)Educationandskillinprimarycare

andcommunity,preventive,andpopulation-basedmedicineCollaborativemedicalresearch;clinicalconsults;trainingforphysicians,etc.Partners/membersTheMedicalSchoolforInternationalHealth

(MSIH)isa


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collaborationbetweenBen-GurionUniversityoftheNegev

andCUMC.AlsohasaffiliatedAmericanHospital,Paris;FlorenceNightingaleHospital,Istanbul;

andSt.LukesMedicalCenter,Philippines

Note: This is an indicative table for illustrative purposes.

Providerwebsites

and:

www.upmc.com/Pdf/AnnualReport.pdfhttp://residency.dom.pitt.edu/http://www.upmc.com/Communications/MediaRelations/BusinessandInternational/Articles/ItalianBST.htmhttp://www.upmccancercenters.com/news/upci_news/2008/022508_dublin.htmlhttp://hms.harvard.edu/hms/facts.aspwww.gtnspa.com/preseseminarioalma/Role%20of%20e-Learning%20Holliday.pdfhttp://www.hmsdc.hms.harvard.edu/affiliations.htmlhttp://www.hmiworld.org/hmi/issues/jan-feb08/feature-uh.phphttp://www.mskcc.org/mskcc/html/511.cfmhttp://cancercenters.cancer.gov/cancer_centers/mskcc.html

http://www.mskcc.org/mskcc/html/5263.cfmhttp://www.cornellmedicine.com/abo_us/?name1=Chairman%27s+Message&type1=2Active


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http://news.med.cornell.edu/wcmc/wcmc_2008/06_06_08.shtmlhttp://www.med.cornell.edu/affiliations/affiliations.htmlhttp://www.dukemedicine.org/AboutUs/FactsAndStatistics

http://www.dukemedicine.org/Initiatives/Singapore/viewhttp://www.hopkinsmedicine.org/about/statistics/hr.htmlhttp://www.hopkinsmedicine.org/admissions/innovat.html


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Medical Tourism

Non-U.S.-basedInternationalProviders

Bumrungrad Hospital, Thailand

BumrungradisthelargestprivatehospitalinSoutheast

Asia,with554bedsandover30specialtycenters.Recently,itmademedical

tourism its focus

Internationalpatients:400,000Patientstreated:1,000,000Apollo Hospitals, India

ApolloisthelargestprivatehealthcareproviderinAsia,withover

8,000bedsin


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morethan41hospitals.Itwasthe

firsthospitalinIndiatoreceiveJCIaccreditationTheApolloGroup

andJohnsHopkinsMedicineInternationalhavetied-uptoundertake a study on heart diseases in India

NationalCancerCenter,

Singapore

NationalCancerCenterSingapore(NCCS)offers treatment for a range of cancerproblems. It has the largest number of

cancerspecialistsinSingaporeandservesas

a referral center for the East Asia region

NCCS

regularlysendsits


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physicianabroadtolearn new technologies

Procedures

Procedures

Procedures

Procedures

CIMA Hospitals, Costa Rica

CIMAHospitalisaffiliatedandintegratedas a teaching hospital with the Baylor

UniversityMedicalCenterof

Dallas,Texas

ThehospitalisoperatedbytheInternationalHospitalCorporationItistheonlyhospitalinCentralAmericathatis accredited by the Department of Veterans

Affairs.It


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hasappliedforJCIaccreditation

American Hospital, U.A.E.

AmericanHospitalDubaiisa143-bed,acute-care,generalmedical/surgical

privatehospitalwith60U.S.Board-certifiedphysiciansformulti-specialtygrouppracticeFirst

hospitalintheMiddleEasttobeawardedJCIaccreditationHasCentersofExcellenceandspecializedclinics for a number of diseases

St. Lukes Medical Center, Philippines

St.LukesMedical

Centerisone


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ofthemostprominenthospitalsinthe

PhilippinesandAsiaThe650-bedhospitalishometonineinstitutes,

13departments,and19centersIthassignedanaffiliationagreementwith

Memorial-SloanKetteringCancerCenterProcedures

Procedures

Procedures

6. Cardiovascular procedures7.Oncology8.Fertility/sexreassignment9.WellnessIvo Pitanguy Clinic, Brazil

The

renownedIvoPitanguy


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Clinicwasfoundedin1963byProfessor

IvoPitanguy,who is in charge of the medical surgical staff

A14-bedprivateclinic,italso

includesaCosmetologyDepartmentforstate-of-the-artprocedures and general skin treatments

NotaccreditedbyJCI

Note: Insights drawn from company web sites: www.bumrungrad.com; www.apollohospitals.com; www.nccs.com.sg; http://www.hospitalcima.com/; www.ahdubai.com; www.stluke.com.ph; http://www.pitanguy.com/ and the bookPatientBeyondBorderbyJosefWoodman.


123456789

NotPresent

1.Orthopedic


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procedures2.Neurosurgery/neurology3.Weightloss/liposuction4.

Cosmetics/plasticsurgery5.DentalproceduresSpecialized

Present


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Medical Tourism19Inbound Medical TourismIn 2008, more than 400,000 non-U.S. residents will seek care inthe United States and spend almost $5 billion for health services.(Figure 17).

Inbound medical tourism represents two percent of the users ofU.S. hospital services. Inbound tourists are primarily from the MiddleEast, South America and Canada. The motivations behind inboundmedical tourism vary. For example, affluent consumers from emergingcountries come to the U.S. for services unavailable in their nativecountries. Some medical tourists want to avoid extended waitingtimes at home. Other consumers combine business or leisure travelwith a specialized medical need. Most come for a medical or surgicalspecialty program requiring hospital-based care (Figure 18).Figure 17: U.S. Inbound Medical Tourism Patient Flow, 10 Year Projection (thousands)Upper Bound

Base ModelLower Bound01002003004005006007008009001 2 3 4 5 6 7 8 9 10 11

Assumptions................................................................................................................................................................................10..........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................11....................................................................................................................................................................................................................................................................................................................Insights The number of patients has fallen from 2001; especially,from Middle Eastern nations, pursuant to delay in visaprocurement and other external environmental factors Many providers are currently making efforts to get moreinternational patients because they do not have theProcedures Sought constraints of managed care in terms of costs

Cancer/oncology Orthopedic Cardiovascular


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CosmeticCategory of Travelers Emerging countries: Seek qualitycare or critical treatments Developed countries: Seektreatment due to waiting timeor criticality issues

Cosmetic/leisure: Vacationor convenience elementduring travelProvider CountryMedical Traveler CountryFigure 18: Inbound Tourism 2008 Deloitte Development LLC. All rights reserved.Note: Insights are drawn from the following articles:Report: A Study of the Impact of International Patients on the John Hopkins University of Medicine, CPT Robert A. Harris,USAF MSC, February 1999The Best Money Can Buy: Medical Tourism in the U.S.A., New America Media, News Fea

ture/Analysis, Hilary Abramson,posted February 2, 2006Challenges and Opportunities in the Care of International Patients: Clinical andHealth Services Issues for AcademicMedical Centers, Don R. Martin, MD, Acad Med. 2006; 81:18919210 Advance data from Vital and Health Statistics, Centers for Disease Control, July 12, 2007. Available at: http://www.cdc.gov/nchs/data/ad385.pdf11 2008 Deloitte Development LLC. All rights reserved.


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Medical Tourism

Inbound medical tourism is modest in terms of volume (Figure 19), but

itis

stillimportanttoahospitalsbottomline.Inboundmedicaltourists

tend to pay commercial charges or higher for medical services, andtend to be more affluent than general patient populations.

Figure 19: U.S. Inbound Demand

Year 20072008 2009 2010201120122013201420152016

2017BaseCasePatients(thousands)417430443456470484498513529544561LowerBoundPatients(thousands)238 246253261268 276285

293 302 311320Upper


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BoundPatients(thousands)596614632 651671

691712733755778801

Notes:

In

2005,therewere44.95millioninpatientproceduresperformedintheUnitedStates.12

Assumesthat25percentofproceduresareconductedinahospitalwithinternationalpatients.Internationalpatientsrepresentapproximately3.5percentofinpatientprocedureswith

arangeof


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2-5percentforthelowerandupper

bound.13Theannualproceduregrowthrateis3percent.Assumes

oneprocedureisequivalenttoonepatient. 2008 Deloitte Development LLC. All rights reserved.

Several initiatives have helped to promote clinical programs relatedto U.S. inbound medical tourism. The establishment of international

partnerships

andtheformationofinternationalhealthcareprojects

have increased awareness of the opportunities for foreign patients totravel the U.S. for care. Also, many U.S. medical centers have listedtheir services in international medical directories. Foreign physiciansand U.S. physicians training abroad have helped to increase thenumber of referrals to the U.S. In addition, many U.S. medical centershave made an effort to serve embassy contacts and the relatives ofethnic groups within their community.

A significant source of medical tourism into the United States is thebordering countries of Canada and Mexico. While Canada has auniversal health care system, patients are hampered by long waitingperiods for many specialized procedures. Some Canadian patientstravel to the United States to avoid these excessive waiting periods and

to

accessthehigh-quality


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careatmajormedicalcenters.InMexico,

some medical tourists have entered the United States hoping to receiveemergency care without having to endure high medical costs, or toobtain U.S. citizenship for their babies.

CharacteristicsofInbound

Medical Tourism Programs

Most U.S. inbound medical tourism programs provide five categoriesof care (Figure 20). The primary focus, however, is on acute programs

thatrequireaninpatientstayforamajormedical

conditionorsurgical

intervention. In most cases, virtual consulting and primary care services aresecondary dimensions of these efforts rather than standalone offerings.

Figure 20: Types of Medical Facilities and Services ProvidedVirtualConsulting:ProvidesconsultationvirtuallywithtechnologyliketelemedicinetoascertaintreatmentandneedfortraveltoU.S.for medical procedurePrimaryCare:Providedforthiskindofcareprovidedforprocedures like annual health checks ups done for outpatientinternational medical travelersSecondaryCare:Referredpatientsfromothermedicalpractitionersfor specialized consultations and medical procedures like that ofcardiology and orthopedicTertiaryCare:High-endmedicalservicesofferedtopatientsfor critical medical procedures like cancer care andneurosurgeryAcademicMedicalCenters/HealthCareNetworks:Widerange of clinical programs covering entire spectrum ofmedical services 2008 Deloitte Development LLC. All rights reserved.

Note:Definitionswereself-definedanddevelopedfromarticlesinAppendixI.123


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4512 Advance data from Vital and Health Statistics, Centers for Disease Control, July 12, 2007. Available at: http://www.cdc.gov/nchs/data/ad385.pdf13 2008 Deloitte Development LLC. All rights reserved.


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Figure 21: How do U.S. institutions account for foreign cultures and health carebeliefs?Whyprovidersneed tounderstandforeign healthcare beliefs

Toenhancehealthcareaccessanddelivery,providers need to understand social andcultural differences among internationalmedical travelers Sensitizingtobothsocial/cultureandgender requirements will help providers tocommunicate better with patients and createatrustingandlong-lastingrelationshipThepracticeofcross-culturalmedicineisnotnewintheU.S.10%ofU.S.residentsareforeign-bornand14%donothaveEnglishastheir first language Religion:Patientsandtheirfamilymayrequirea prayer area or a priest in order to pray orconduct a religious ceremonyCustomandBeliefs:Differentregionsoftheworld have customs and beliefs which mayneed to be adhered to in order to obtain a

desired outputSomehospitalsprovideachapelandPastoralservices;forexample,BaptistHospital(NewEngland),JohnHopkinsProvidershavefemalephysiciansfortreatingfemalepatients,ifaparticular culture requires that Language:KnowledgeofmedicalterminologyinthepatientslanguageaswellasEnglishwillaidincommunication between the physician and patient Diet:Dietsdifferbyreligionandregion.Forcertain patients it is important for themeattobeHalal(madeinacustomaryway)Providershaveinterpretersandhelplinesforround-the-clocktranslationand interpretation service

Providershaveseparatekitchensand menus which are prepared withspecific customs and beliefs in mind CAM:Patientsmaysometimesneedalterativetherapy and medical care during or after theirtreatment Culturewithrespecttohealthanddisease:Sensitivityinthisareaaidsinunderstandingthe patient and how to treat him better27%ofhospitalsofferedoneormoreCAMservicein2005**Survey,AmericanHospitalAssociationInAMCssuchasJohnsHopkins,international medical graduates actas patient coordinatorsReligionandCustom/BeliefsLanguage and DietCAM*treatmentandPersonalHealthcareRelatedBeliefs*Complementaryandalternativemedicine 2008 Deloitte Development LLC. All rights reserved.Note: Insights developed from:(1)Hospitalwebsites:MayoClinic:http://www.mayoclinic.orgNewEnglandBaptistHospital:http://www.nebh.org/sites/nebh/home.aspJohnHopkins:www.hopkinsmedicine.org(2) http://nccam.nih.gov/news/newsletter/2006_fall/hospitals.htm(3)Sourcesofinformationaboutdifferentreligiouspracticesen.wikipedia.org/wiki/Eucharistic_adorationwww.stmarys-hospital.com/Services/Pastoral.aspxwww.public.asu.edu/~squiroga/leigh.HTMHealthCareDeliverytotheArabAmericanCommunity;April,1999;http://erc.msh.org/provider/arab_excerpt.pdfPreventingEthicalDilemmasfromPediatricNursing:TheMuslimPeoplehttp://www.medscape.com/viewarticle/457485_2Whyprovidersneed to

understandforeign healthcare beliefs


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Toenhancehealthcareaccessanddelivery,providers need to understand social andcultural differences among internationalmedical travelers Sensitizingtobothsocial/cultureandgender requirements will help providers tocommunicate better with patients and createatrustingandlong-lastingrelationshipThepracticeofcross-culturalmedicineisnotnewi

ntheU.S.10%ofU.S.residentsareforeign-bornand14%donothaveEnglishastheir first language Religion:Patientsandtheirfamilymayrequirea prayer area or a priest in order to pray orconduct a religious ceremony CustomandBeliefs:Differentregionsoftheworld have customs and beliefs which mayneed to be adhered to in order to obtain adesired outputSomehospitalsprovideachapelandPastoralservices;forexample,BaptistHospital(NewEngland),JohnHopkinsProvidershavefemalephysiciansfortreatingfemalepatients,ifaparticular culture requires that Language:KnowledgeofmedicalterminologyinthepatientslanguageaswellasEnglishwillaid

incommunication between the physician and patient Diet:Dietsdifferbyreligionandregion.Forcertain patients it is important for themeattobeHalal(madeinacustomaryway)Providershaveinterpretersandhelplinesforround-the-clocktranslationand interpretation serviceProvidershaveseparatekitchensand menus which are prepared withspecific customs and beliefs in mind CAM:Patientsmaysometimesneedalterativetherapy and medical care during or after theirtreatment Culturewithrespecttohealthanddisease:Sensitivityinthisareaaidsinunderstandingthe patient and how to treat him better

27%ofhospitalsofferedoneormoreCAMservicein2005**Survey,AmericanHospitalAssociationInAMCssuchasJohnsHopkins,international medical graduates actas patient coordinatorsReligionandCustom/BeliefsLanguage and DietCAM*treatmentandPersonalHealthcareRelatedBeliefs*Complementaryandalternativemedicine 2008 Deloitte Development LLC. All rights reserved.Note: Insights developed from:(1)Hospitalwebsites:MayoClinic:http://www.mayoclinic.orgNewEnglandBaptistHospital:http://www.nebh.org/sites/nebh/home.aspJohnHopkins:www.hopkinsmedicine.org(2) http://nccam.nih.gov/news/newsletter/2006_fall/hospitals.htm(3)Sourcesofinformationaboutdifferentreligiouspracticesen.wikipedia.org/wiki/Eucharistic_adorationwww.stmarys-hospital.com/Services/Pastoral.aspxwww.public.asu.edu/~squiroga/leigh.HTMHealthCareDeliverytotheArabAmericanCommunity;April,1999;http://erc.msh.org/provider/arab_excerpt.pdfPreventingEthicalDilemmasfromPediatricNursing:TheMuslimPeoplehttp://www.medscape.com/viewarticle/457485_2Catholics IslamEucharistic adoration: a specificprayerpracticeinwhichHoly

Diet:Patientsfollow


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halalorMuslimkosherrequirements.Theypatient

Communion is brought to themealsmusthavenon-porkorvegetarianLatin Americans IslamLocaltreatments:Somepatients

may have used the services of acurandero(localhealer).ThoseCulture: During the month ofRamadan,providersshouldbeawareof fasting requirements to help themto provider

treatment details should be knownmake proper clinical interventions


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Medical Tourism

Major Centers for Inbound Medical Tourism

Texas Medical CenterHas the largest air ambulance service

and a successful inter-institutionaltransplant programUniversity of PittsburghMedical CenterOffers integrated health care deliverysystem & health plansHarvard MedicineThird-oldest medical school in theU.S. Its not-for-profit subsidiaryfocuses on international operationsJohns Hopkins HospitalTeaching hospital in Maryland

founded by Johns HopkinsCleveland ClinicOffers both clinical and hospital carewith research and education (fifthlargestresearch institute in U.S.).Ranked #1 in heart care by U.S. News& World ReportMayo ClinicThe largest integrated group practicein the worldDescriptionEmployee

strength:73,600(morethan26,000registerednurses,LVNs,clinicalcaregivers,technicians & medical support staff and 13,000 volunteers)Numberofpatients:5.5MpatientvisitsKey focus area(international)Allspecialtiesarecovered

Largestnumber


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ofheartsurgeriesperformedintheworld

Partners/members46institutionsoftheTexasMedicalCenterinclude13

renownedhospitalsandtwospecialtyinstitutions,two medical schools, four nursing schools, and schools of dentistry, public health and pharmacyDescription Employeestrength:43,000employees

Numberofpatients:Morethan3millionoutpatientvisits&morethan165,000inpatientvisitsKey focus area(international)Alltransplantations,cancer,neurosurgery,psychiatry,rehabilitation,

geriatrics,womenshealth


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and many othersPartners/membersComprises19hospitals,

andanetworkofothercaresitesacrosswesternPennsylvaniaHas

partneredwithItalysregionofSicilytodevelopahospitalinPalermoDescription

Employeestrength:10,458facultymembersinclinicaldepartmentsofaffiliatedhospitalsandinstitutions with a total of over 3,000 bedsNumberofpatients:Offersservicestoover2millionpeople

intheBoston


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regionKey focus area(international) Allspecialtiesarecovered

Partners/membersInadditiontoaffiliatedinstitutes,has100PrimaryCare

CentersHasdevelopedmorethan50programsinover30countriesacross

fivecontinentsDubaiHealthcareCityislaunchingUniversityHospital,a400-bedtertiarycareteachinghospitalDescription Employeestrength:over25,000Numberofpatients:

60,000admissionseach


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yearandmorethan500,000outpatientvisits

Key focus area(international)Collaborativeresearch,education,trainingtophysicianandothertechnical

staff,policyplanning,medical servicesPartners/membersHastieswithreputedinstitutesin

Japan,Singapore,India,UAE,Canada,Lebanon,Turkey,Ireland,Portugal,ChileandPanamaCityDescription Employeestrength:1,400physiciansNumberofpatients:Morethan3

millionoutpatientvisits


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&68,000surgicalcasesperyearKey focus area

(international) Over120medicalspecialtiesandsub-specialtiesPartners/membersInadditionto

themaincampusandhospitals,haseightmoreclinichospitalsClevelandClinic

AbuDhabiinpartnershipwithgovernmentofUAEisscheduledtobeoperationalin 2010DescriptionEmployeestrength:Employsmorethan2,500physicians&scientists

andover42,000


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alliedhealth staffsNumberofpatients:135,000

patientvisits&10,000internationalpatientsKey focus area(international) Allspecialtiesarecovered

Partners/membersHasfourmajorclinics:Rochester(MN),Jacksonville(FL)andPhoenix

andScottsdale(AZ)OperatesinmanysmallerclinicsandhospitalsinMinnesota,Iowa&Wisconsin(MayoHealthSystem)


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Medical Tourism

Major Centers for Inbound Medical Tourism (cont.)

Cornell Medical SchoolWeill Medical College of Cornell

University was founded in 1898;affiliated in 1927 with New York-PresbyterianHospitalDescriptionEmployeestrength:240full-time,265voluntary

and775networkfacultymembersNumberofpatients:Nearly2millionpatient

visitsperyear,includingmorethan230,000visitstoitsemergencydepartments(NewYork-PresbyterianHospital)Key focus area(international) Researchandeducation,withallspecialtymedicalcare

Partners/members


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HasopenedamedicalschoolinQatar

andaresearchandadvisoryinstituteinSeoulMaintainsaffiliationswith

MemorialSloan-KetteringCancerCenter,HospitalforSpecialSurgeryand metropolitan-area institutionsDuke University School ofMedicine (DUMC)Hasbeen

votedthebest-qualityhospital in the Durham-Chapel Hill areaDescription Employeestrength:8,648full-timeemployeesNumberofpatients:Morethan1.4millionoutpatientvisits&60,000surgicalcasesper

yearKey focus area(international)


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Allspecialties,witheminenceincardiacand

organtransplantcarePartners/members DUSMhaspartneredwithNUStoopen

Duke-NUSMedicalGraduateSchoolSingaporeMemorial Sloan-KettreringCancer CenterOneoftheworldspremiercancer

centersDescription Employeestrength:9,000Numberofpatients:About21,000inpatientsandmorethan431,000outpatientvisitsannuallyKey focus area(international) Advisoryservicesfora

widespectrumof


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cancersPartners/membersHasestablishedrelationships

withinstitutionsaroundtheworld:HongKong,Barcelona,Geneva,Athens,SaoPaulo,

Seoul,Istanbul,SingaporeandPhilippines

Note: This is an indicative table for illustrative purposes.

Providerwebsitesand

thefollowingwebpages:

http://www.texmedctr.tmc.edu/root/en/GetToKnow/FactsandFigures/FactsAndFigures.htmhttp://www.texmedctr.tmc.edu/root/en/GetToKnow/AboutTMC/About+the+TMC.htmhttp://www.texmedctr.tmc.edu/root/en/GetToKnow/AboutTMC/About+the+TMC.htmhttp://health.usnews.com/usnews/health/partners.htmhttp://www.mayoclinic.org/mcitems/mc0700-mc0799/mc0710-2007.pdfhttp://www.washingtondiplomat.com/04-02/c5_04_02.htmlhttp://www.mayoclinic.com/health/AboutThisSite/AboutMayoClinicAWordaboutIntrabound

Medical Tourism Domestic


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Centers of Excellence

A less significant form of medical tourism occurs when patients travelto non-local facilities or Centers of Excellence within their homecountry to receive medical treatment. Drivers include the availabilityof a physician who performs a complex or specialty procedure,

decreasedwaitingtimes,higherqualityofcare,lowercosts,andinclusionof

thefacilityundercoverageprovisionsoftheindividuals

insurance program.

While data about intrabound medical tourism is sparse, its prevalence

is widely assumed. The patient volumes of leading cancer centers(e.g., Mayo, Hutchinson, MD Anderson, Hopkins), research hospitals(e.g., Washington University St. Louis, Massachusetts General,Stanford, Mt. Sinai) and many other specialty hubs are impactedby individuals who are self-referred or physician-referred based onperceived and/or demonstrated specialized expertise. In addition,

healthplanshavesupportedmedicaltourism:UnitedHealthcaresUnitedResourceNetworkandAetnasCentersofExcellencefor

transplants and bariatric surgery are examples.


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Intrabound medical tourism is likely to grow with consumerism and theresulting demand for transparency in prices and clinical performance(Figure 23). However, it is currently difficult to measure the trendbecause data are not available.


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Medical Tourism

Looking Ahead

Thegrowth

ofmedicaltourismisdrivenbycost,consumerism,quality,

and foreign economic development. Outbound medical tourism is

expected to increase as health care costs in the United States continueto rise. In addition, consumerism and higher out-of-pocket expensesare prompting individuals to seek lower-cost alternatives to U.S.-basedtreatments. Inbound medical tourism is primarily driven by the search for

high-qualitycarewithoutextensivewaitingperiods.Foreignpatients

are

willing to pay more for care within the United States if these two factorsplay a large role. Finally, economic development abroad and the growthof U.S.-based international programs should help to meet medical

tourismscapacitydemands,atleastintheshortterm.

Outbound medical tourism is likely to experience explosive growth overthe next three to five years, followed by continued slower growth dueto capacity constraints. The availability of lower-cost, offshore treatmentoptions could save U.S. patients billions of dollars and reduce spendingwithin the U.S. health care system. Inbound medical tourism is alsoexpected to grow, but at a much slower and steadier rate than outboundmedical tourism (Figures 22 and 23). Academic medical centers and

majorhealth


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systemswithpartnershipsabroadarelikelyto

leadtheway

in this sector. Intrabound medical tourism may expand as health insurersand consumers begin to leverage cost and performance data to take

advantageofregionaldifferences

inpricing,quality,customersatisfactionandwaitingtimes.However,itisnotexpected

tobeamajorcomponent

of medical tourism until this data becomes more transparent.

Figure 22: Spending by Inbound Medical Tourists

Figure 23: U.S. Inbound Medical Tourism Spending, 10 Year Projection (billion U.S.$)

$14$12$10$8$6$4$2$0

2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017

Upper Bound


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Base Model

Lower BoundAssumptions

................................................................................

................................................................................

................14

................................................................................

................................................................

..................................................

................................................................................

................................................................................

........

................................................................................

..........................................15

................................................................................

..............

........................................................................................................

................................................................................

........................

Year 2008 2009 20102011201220132014

201520162017BaseCaseSpending(billionsU.S.$)4.75.05.35.66.0 6.3 6.77.17.68.0LowerBoundSpending(billionsU.S.$)2.72.9 3.0 3.2 3.43.6 3.8 4.14.3

4.6UpperBound


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Spending(billionsU.S.$)6.77.17.68.0 8.5

9.0 9.6 10.210.811.4

Note:Theweightedpriceofaprocedure

inaforeigncountrywasmultipliedbytheflowofoutboundU.S.patients.

Inflation-adjustedusingarateofthreepercent.


14 Advance data from Vital and Health Statistics. Centers for Disease Control. July 12, 2007. Available at: http://www.cdc.gov/nchs/data/ad385.pdf15 2008 Deloitte Development LLC. All rights reserved.


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Medical Tourism

Implications

Provider Organizations

Asinboundmedicaltourismexpands,themajorityofgrowthwillbe

atthemajoracademicmedicalcenterswhichhaveestablished

partnerships with international programs. These medical centers willlook to expand their capacity to accommodate the growth in foreign

medicaltouristslookingtoobtainqualityhealthcarewithouthaving

to wait extended periods of time.

Health Plans

The expansion of medical tourism creates several opportunities forhealth insurers. The low-cost alternative of receiving care abroadenables insurers to develop plans that provide incentives for patientswilling to travel for various procedures. As the cost of health carecontinues to rise in the United States, leveraging low-cost careabroad can help health insurers to increase profitability.

Employers

Employers are seeking less-costly care options for their employees.


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Medicaltourismwillcaptureemployersinterest,but

theywillneed

to sell it to their employees. A partnership with health insurers thatoffer medical tourism to U.S. patients can help to reduce the financialburden of offering health insurance among all employees.

Regulators and Policymakers

Medical tourism provides considerable opportunities for regulators

and policymakers to create initiatives that will enable greater accessto health care. However, the U.S. government may be cautious whenconsidering the promotion of an industry that will likely create a

lossofpotentialspendingintheU.S.Also,assurance

ofqualitycare

abroad will likely be a growing concern of policymakers.

ImpactofOutboundandInboundMedicalTourism

Stakeholder ImpactProviderOrganizationsInboundmedicaltourismcouldspawn

academicmedical(AMC)


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growthopportunities.Specifically,AMCs may need to expand capacity to manage the influx of inbound patients.Outboundmedical

tourismmeansthattheconceptofoffshoringwillnowhitphysiciansand

hospitals,industries never thought to be at risk for global competition. For example, WestVirginia recently passed abill to send state employees abroad for treatment.Intraboundmedicaltourismwillcreateintensecompetitionbetween

winnerandloserorganizations.Competitionwillbebasedondemonstrablevaluepropositions(price,quality,service)mitigatedbyconsumer/employer/government-sponsored insurance programs.HealthPlansInboundmedicaltourismsimpact

willbeminimal


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unlessforeignpatientsbuycertaincriticalillness

policiesto pay for their condition. Opportunity exists for health plans to create products targeted to inboundmedical tourists to facilitate price negotiation and care coordination.Outboundmedicaltourismprovideshealthplansadditional

networkoptionsforcost-effectivecarethatcan be incorporated as features in group and individual products. Health plans may need to decreasepremiumsforemployerswhosend

theiremployeesabroadformajor,non-urgentsurgeries.Riskscouldincludeexposuretoaforeigncountrysmedicolegalsystem;nursesandotherstaffmightnotbeas

qualifiedasthose


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intheU.S.Intraboundmedicaltourism

likewisewillbedrivenbyhealthplanproductdesign.Itofferspotential

forcustomization of insurance programs for individuals and groups.Employers Inboundmedicaltourismn/aOutboundmedicaltourismwill

becomeaninterestingoptionforemployersasacost-managementhedgefor services that are safe, effective and less costly. Self-insured employers will need to consider the risk ofmalpractice suits.Intraboundmedicaltourismwillalsobeofinteresttoemployers,if

theyaregiven


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theopportunitytonarrowphysician networks to high-performing, efficient and less-costly providers. However, tension with localcommunity providers is a likely result if employers direct employees out of the

immediate community.Regulators and Inboundmedicaltourismn/aPolicymakersOutboundmedicaltourism

isacomplexregulatoryissue:Medicalliability,riskmanagement,oversightofdevices and prescription drugs, credentialing of providers, et al, are more complicated offshore. It is not likely

thatthegovernmentwilldirectenrollees(Medicare,Medicaid,FEHP)inthedirectionofoutboundmedicaltourism, but it is plausible that barriers will not be created for commercial plans, employers and individuals.Intraboundmedicaltourismtohigh-qualityspecialtyhubs

mightbeattractive


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topolicymakerswheredemonstrablequalityandefficiency

gainsareachievable.



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Medical Tourism

Access this report online alongwith other related Center research

To access a copy of the Medical Tourism: Consumers in Search ofValue report online please visit: www.deloitte.com/us/medicaltourism

To access other research produced by the Deloitte Center for HealthSolutions please visit: www.deloitte.com/us/centerforhealthsolutions

Subscribe.

To receive complementary e-alerts when new research is publishedplease register at: www.deloitte.com/centerforhealthsolutions/subscribe

Appendix

I

The following articles provided insights:

DevonM.Herrick,MedicalTourism:GlobalCompetition

inHealthCare,NCPAPolicyReportNo.304,November2007MarthaLagace,TheRiseofMedicalTourism,Q&AwithTarunKhanna,publishedDecember17,

2007An


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EmergingHealthcareSolutiontoExorbitantHealthcareCosts

forUninsuredandUnderinsuredAmericans,Medretreat,accessed at http://www.medretreat.com/ 12/23/07

CPTRobertA.

Harris,USAFMSC,Report:AStudyoftheImpactofInternationalPatientson

theJohnsHopkinsUniversityofMedicine,February1999HilaryAbramson,TheBestMoneyCanBuy:MedicalTourismintheU.S.A.,NewAmericaMedia,News

Feature/Analysis,postedFebruary


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2,2006DonR.Martin,MD,

ChallengesandOpportunitiesintheCareofInternationalPatients:ClinicalandHealth

ServicesIssuesforAcademicMedical Centers, Acad Med. 2006, 81:189192

AFeasibilityStudyforaYukon

HealthandWellnessTourismIndustry,Whitehorse,Yukon,May2005StuartAltman,DavidShactmanandEfratElat,CouldU.S.HospitalsGotheWayofU.S.

Airlines?ADarth


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VaderScenario,presentationtoHospitalPaymentSymposium,

Washington,DC,July15,2005KatrienKesteloot,PhD,HealthCareMarket

Reforms&AcademicHospitalsinInternationalPerspective,Achtergrondstudie,Zoetermeer,2003SaraCaballero-Danell

andChipoMugomba,MedicalTourismanditsEntrepreneurialOpportunitiesAConceptualFrameworkforEntryintothe Industry, School of Business and Economic Law, Goteborg University, January 2007

OliviaF.Lee,MBAand

TimR.V.


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Davis,PhD,InternationalPatients:ALucrativeMarket

forU.S.Hospitals,Health Marketing Quarterly,Vol. 22(1), 2004WilliamBies,LefterisZacharia,MedicalTourism:

OutsourcingSurgery,KatzGraduateSchoolofBusiness,UniversityofPittsburgh,Pittsburgh,PA,Department

ofMedicine,UniversityofPittsburgh,Pittsburgh,PA;ReceivedNovember28,2006;acceptedMarch14,2007IMTJ (International Medical Travel Journal) articles:InsuranceandMedicalTravel,September24,2007

PremiumService,


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November1,2007USA:theCost

ofHealthcare,June18,2007


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Medical Tourism

AppendixII

The following web sites provided insights:

http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=2234298SomeCompanies,InsurersMullSendingAmericansAbroad

forSurgery,November4,2006.Westchester Journal News, downloaded from:www.bcbshealthissues.comVariousreadingandsites:

http://www.project-management.in/http://en.wikipedia.org/wiki/Medical_tourism#Historyhttp://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=2234298http://www.discovermedicaltourism.com/hungary/http://www.treatmentinhungary.net/http://www.discovermedicaltourism.com/hungary/http://www.treatmentinhungary.net/http://www.arabmedicaltourist.com/http://timesofindia.indiatimes.com/articleshow/2924252.cmsOver150,000medicaltouriststravelledtoIndia

in2002alone...


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numberofsuchtravelershasbeenincreasing

byatleast25%everyyear150,000(2002);25%growthrate

till2007Cost:Avg.20%ofU.S.:Seetable"Figure5

Costs"belowfordetailshttp://www.thaiwebsites.com/medical-tourism-thailand.aspCost:Avg.30%ofU.S.Seetable"Figure5Costs"belowfordetailshttp://en.wikipedia.org/wiki/Medical_tourism#SingaporeCost:

Avg.35%of


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U.S.Seetable"Figure5Costs"

belowfordetailshttp://www.eturbonews.com/2692/malaysia-worlds-top-five-medical-tourism-destCost:Avg.25%ofU.S.

Seetable"Figure5Costs"belowfordetailshttp://www.eturbonews.com/2692/malaysia-worlds-top-five-medical-tourism-desthttp://www.discovermedicaltourism.com/malaysia/

http://www.project-management.in/malaysia.phphttp://www.traveldailynews.com/new.asp?newid=27041&subcategory_id=69http://www.traveldailynews.com/new.asp?newid=27041&subcategory_id=69http://www.brazilmedicaltourism.com/mostrar_post.php?id=17&

hr medical tourism

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