More people are traveling abroad for medical procedures, often with the blessing of both their employer and insurance carrier. According to a recent report by Visa and Oxford Economics, the global medical tourism market totaled $439 billion in 2015 and will grow 25% annually over the next decade. That figure was subsequently revised downward to $50 billion, the International Medical Travel Journal notes, but it is still a significant market. Driving this trend are increasing access to high-quality care and services outside the U.S., lower costs, the chance to couple treatments with attractive destinations and availability of treatments and drugs not approved or available stateside.
While cost is just one reason people travel for care, it can be a compelling one if the foreign provider is reputable. Consider a knee replacement, for example. The procedure can cost anywhere from $35,000 to $60,000 in the U.S., but costs less than $23,000 in Costa Rica or India, according to The Fiscal Times. The most common procedures people travel for are heart surgery, cosmetic surgery and dentistry.
While the majority of medical tourists flock to the U.S. for care, Thailand, Singapore, German, South Korea and Spain are fast catching up, the report says. India is also a major destination for medical tourism, particularly for cardiac care. Understanding these travel patterns and the opportunities for attracting patients can provide a valuable added revenue stream for hospitals that position themselves in this market.
The Centers for Disease Control and Prevention estimates that up to 750,000 U.S. residents travel abroad each year for medical care, a mere drop in the bucket compared with the nearly 37 million patient discharges from U.S. hospitals reported in 2011.
Diversified revenue stream
One might expect that states like Washington, which abuts British Columbia, would see substantial numbers of individuals crossing the border north for medical procedures. But Mary Kay Clunies-Ross, spokesman for the Washington State Hospital Association, says she hasn’t seen any significant impact on local hospitals.
“Some of our hospitals do get international patients, but that is usually in the context of seeking needed services from a specific program or provider (e.g., they might come to be treated at Fred Hutchison Cancer Research, or bring a child to Seattle Children’s Hospital for pediatric specialty care),” she writes in an email. “I don’t know of any international marketing campaign.”
Most U.S. hospitals haven’t figured out that medical tourism could be a revenue diversification strategy, and they’re too mired in the Affordable Care Act, PCORI reporting, managed care contracting and other obligations to promote themselves as a specialty surgery or magnet hospital destination, says Maria K. Todd, CEO of Mercury Advisory Group in Denver, CO, and an international consultant on healthcare business development. “They just don’t have the bandwidth to figure out how to do the marketing campaign and study the market and still do everything else they have to do.”
Todd, who wrote "Handbook of Medical Tourism and Program Development," sees two categories of U.S. hospitals taking advantage of the travel-to-care trend: Academic medical centers (AMCs) and ambulatory surgery centers (ASCs). AMCs have excess capacity and some of the latest research and technology, but they need cases on which to train new doctors. Medicare alone doesn’t cover the cost of all of that training. As a result, many AMCs are using medical tourism as a diversification strategy to get different reimbursement sources into the mix,” Todd tells Healthcare Dive.
ASCs, on the other hand, are usually selling to price-sensitive customers, Todd says. She points to ASCs in rural areas that are looking for ways to compete with critical care hospitals. The federal government allows CAHs to charge 101% of what Medicare would pay a non-critical access hospital, so an ASC that’s outfitted for overnight beds and can cut the cost of a procedure, and is located near a moderate-priced motel, can bundle together a price-driven medical tourism package and market it to the public.
Brand appeal and cost transparency
Hospitals interested in creating a medical tourism revenue stream should build on what the facility already does well, such as hip replacements or cardiac artery bypass grafts, rather than add a service line or new staff, Todd says. Other critical factors include brand identification and destination.
“What doctors have not understood in America is how to brand themselves … and so it would be very hard for them to claim a medical tourism base, let’s say, in comparison with a doctor who’s a researcher who’s published at the Cleveland Clinic,” she says. “Brand in healthcare translates to trust … and people want to trust that where they get their healthcare is the best choice they could have made.”
Another thing holding hospitals back is determining case rate, says Todd. With CMS’ bundled case rate initiative, hospitals are having to learn how to bundle cases and that requires knowing the cost. But medical tourism is not a fee-for-service, line item percent of charges; “It’s 100% give me an estimate up front,” she explains. The only way to do that well is to define a case rate with contingency for outliers—for example, the rate for a stent procedure would cover three stents and any additional stents would cost $1,500 each.
“With hospitals not knowing their case rates, you can’t do transparent quoting,” says Todd, who likens the situation to asking a grocer for the price of a loaf of bread and then waiting while somebody does a price check.
“The American population demands, if I’m going to fly to you, you need to tell me is this going to cost $7,000 or $17,000, and most American facilities are not prepared to do that on anything more than maybe a hip or a knee [replacement] or a lap band,” she says. “They’re not prepared for contingencies” such as an allergy to an anesthetic that could put the patient in intensive care.
For patients who do choose to travel for care, whether abroad or within the U.S., there’s another thing to consider. Under the CPT code system, Medicare will pay for 90 days of post-operative care at no additional charge. That’s already bundled into the CPT code. But that could be a problem if the patient leaves the city where the procedure was done after a week or 10 days. That leaves the patient’s hometown doctor to provide the other 80 days of follow-up care, and some doctors are refusing to take patients back, according to Todd.
“Some of it is about greed, taking food off my table,” she says, noting the hometown doctor can only bill for evaluation and management, not the procedure itself. Physicians are also concerned that they could be blamed — and sued — for a complication they didn’t cause. With medical complications coverage at one of the leading medical travel insurance programs capped at $50,000, that’s far below the roughly $250,000 malpractice tort liability ceiling in most of the U.S., Todd says.
“You can blow through $50,000 on a case gone bad in no time flat,” she adds. “So if [people] go out of the country and they have a complication, yes, that complication insurance might kick in, but they might still charge the local doctor with the complication.”