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SPOTLIGHT
Jackie Aube

Jackie Aube Vice President of Product Management, CIGNA Healthcare

Jackie Aube is CIGNA HealthCare’s vice president of product management. In this role she oversees the development and enhancement of CIGNA’s core product solutions, and is the company’s product lead for medical tourism. Aube has been with CIGNA for more than 20 years and has held a variety of management positions in contract administration, account implementation, service operations, client services, sales and marketing. She holds a bachelor’s degree in business management from State University of New York, where she was a member of the National Honor Society in Business Administration.

Laura Carabello (MTT): How would you define medical tourism, as the market you deal with here in the U.S. perceives it?

Jackie Aube (JA): In my conversation with others, it’s clear that the perception of medical tourism is predominantly focused on U.S.-based citizens going abroad for the purpose of medical care. Again, that’s the most common definition used by individuals that I deal with here in the U.S.

MTT: Understanding that that’s how we’ll be viewing the term in the context of particular interview, can you share with me how you like the term medical tourism? Do you think it’s descriptive or would you like to see something else -- is it the globalization of health care?

JA: Yes, I think a better term - and one we’ve actually started using internally - is global health care consumerism. I think that is a better term for how we view it here at Cigna.

MTT: Even in the context of focusing on the needs of American citizens to travel outside the country?

JA: Yes.

MTT: Do you currently have contracts with foreign hospitals to take care of your expatriates, citizens, or workers/employees that are living in other countries?

JA: Yes, we do through our Cigna international division. It’s important to understand the distinction between our international division and our health care division. Through our international division we offer our employer customers the opportunity to buy expatriate coverage. So for global companies that send their employees to other countries for business for extended periods of time, the employees will have health care coverage through our international division. We also offer products specifically designed for shorter-term assignments to allow clients to customize based on their unique needs.

MTT: So your international network is made of up the providers who offer care for employers sending employees all over the world?

JA: Yes

MTT: Can you tell us what your U.S.-based members are looking for in terms of a care provider?

JA: Many of our customers are self-insured, which means they fund all of their claims and they have a lot of say in plan design, including specific benefits covered by the plan. I would say that employers who are considering the addition of medical tourism to their U.S.-based policies tend to be the thought leaders in the American employer-based market. They tend to be the early adopters of new trends, and we’re already getting some questions regarding medical tourism and what it means for them.

We are working to develop solutions that will meet the broad range of global healthcare needs. And at this point, there is some interest in international centers of excellence. If a client is considering sending one of their employees abroad for the purpose of medical care, they are going to want to partner with a company that has experience internationally. That same company must also have the ability to consult with them about what they should be looking for in terms of facilities, safety, and quality standards—and all the other logistics you would need to think about if you were going to send an employee abroad for medical care.

MTT: If you could quantify, how many inquires would you say you’ve received?
JA: We’ve had probably 20 or so inquiries from employers and approximately 40 inquiries if you include consultants and the media. But that’s just inquires— most of the employers that we have spoken to are interested in finding out more about medical tourism but haven’t made the decision to add medical tourism benefits to their plan.

MTT: If you had to qualify to what extent Cigna is embracing this concept, would you say it’s a low, medium, or high level? And what would be your role in making decisions related to pursuing it?

JA: My role as product lead is to monitor the trends very closely and to chart a course for Cigna that would ensure that we have solutions to meet the demand. I would say that in terms of pace, we are really letting the market drive that pace. We have received a fair amount of inquiries, but I think employers are appropriately cautious. It’s very new, so we are certainly willing to work with employers that are interested in pursuing the concept further.

MTT: I want to ask you this personally because people ask me this because of the newsletter: Would you personally consider going out the country for medical care?

JA: I think if I had not been working on this particular initiative my answer would have absolutely been “No.” But through the research I’ve been doing on behalf of Cigna, I’m now more aware of the existence of high-quality facilities outside of the US and the extent of the training of the physicians that practice in these facilities. When you consider this in addition to JCI’s involvement and the pace at which several foreign hospitals are now seeking independent quality accreditations, I’d have to say that now I’m warm to the idea. Very warm.

MTT: Would you say that JCI accreditation is a must for Cigna?

JA: I wouldn’t necessarily say so. I think that it always helps to have additional independent reviews, but we are still assessing what the appropriate quality indicators should be. That is probably one area where we feel there is more to do in terms of research.

MTT: I am sure you are familiar with all the other accreditation programs all over the world that seem to want to mirror JCI.
JA: Yes, I am familiar with some of them.

MTT: Given those, what countries would you say would be most appealing to Americans?
JA: We haven’t completed any independent research regarding countries that would rank as most appealing to Americans, but based on employer queries, their interest tends to be focused on where the highest quality facilities are located and what a member would perceive to be high quality.

MTT: Would member perception include a language or culture?

JA: Yes. The ability to speak English is a good example. Patient perceptions begin from the point where they land at the airport until they arrive at the facility where they are going to have the procedure done.

MTT: We talked about quality as being an important factor. But obviously, cost comes into this, too. What are your thoughts on cost as a factor as it relates to quality?

JA: Cost is important. The prospect of getting on a plane and going somewhere for a medical procedure has to include some incentive. I think quality is the biggest bar to overcome because improved health is the goal of any medical procedure. People need to be assured they are going to receive high quality care first, and then the next largest factor is going to be cost – “Is it worth it for me?”

Safety is also a factor. Employers need to consider any additional liabilities that they might be taking on. So, while there are several factors to consider, clinical quality and safety standards are at the top, followed by cost, and then all other implications.

MTT: Do you think there will be issues with insurance and essentially giving up your right to file a lawsuit if you had a bad outcome? Also, how does Cigna handle this matter?

JA: I do think that it’s very important that if an employer intends to offer this as part of its benefit program then it needs to be made very clear to any employee who takes advantage of medical travel that the malpractice laws differ significantly between countries. U.S. medical tourists should understand that restitution for any sort of malpractice is not really matched globally.

MTT: What are the implications for Cigna? Let’s say I was a Cigna member and had a bad outcome in Turkey and hold Cigna responsible for that bad outcome. Do you see that as an issue or as something this industry should tackle?

JA: I certainly think it’s something that needs to be considered. I am a big fan of member education. Full disclosure of all of the benefits and risks is important, as it would be with any medical decision, and this is something Cigna would always support.

MTT: Do you currently have or plan to institute any educational sessions or focus groups for your employers or stakeholders that want to get into this?
JA: We have considered bringing interested employer groups together. In fact, it’s something we are discussing right now. At this point, we are currently meeting with employers one-on-one to determine their individual objectives, what they want to achieve, and their timelines. We intend to discern if they are just in the consideration phase or if they are ready to take action.

MTT: Are you familiar with the term value-based health design? If so, how do you see it fitting into that scenario?
JA: Yes, I’m familiar with it but I don’t see much of a fit. My interpretation of value-based design is really to identify conditions where certain things like cost might prevent members from seeking the care that ultimately will lead to better health. Those types of conditions I categorize as value-based health care are more chronic conditions where ongoing compliance with maintenance medications, for example, is important to an individual’s health, as opposed to the types of procedures that would be most conducive to medical tourism.

Medical tourism is most appropriate for types of procedures that don’t need a lot of pre- or post-operative care, but may be high cost. Surgeries such as hip and knee replacement and some cardiac procedures—such as bypass surgery—fit this description. Value-based health designs focus on designing benefit plans intended to encourage behaviors that mitigate heath problems. For example, reducing or waiving pharmacy co-pays for drugs to lower cholesterol levels.

MTT: How about bariatrics? Are you looking at that?

JA: Bariatric or weight-loss surgery is something that really should be heavily managed both pre- and post-operative. It’s really a mind-body thing. If you have bariatric surgery but have not gone through the right course of pre- and post-op treatment – including counseling for lifestyle changes and associated habits – it is not likely to be as successful, and might even be considered high-risk.

MTT: How would Cigna go about looking at after care?

JA: It is an important consideration that requires deliberate planning. This is under discussion as well.

MTT: Do you envision Cigna having a special network in place for it?

JA: We really haven’t gotten that far.

MTT: That’s fair. This industry is still growing up. How do you see partnerships between U.S.-based hospitals and foreign hospitals and how would that work to the benefit of a plan like Cigna? For example a Johns Hopkins might have a marketing partnership with a hospital in Singapore.

JA: I think that’s a really interesting question because it is obvious that large notable facilities in the U.S. are starting to think globally, and a number of them are already creating sister partnerships internationally or have franchises internationally.

MTT: And if Cigna has contracts with those hospitals, it might be a natural extension?

JA: Yes -- it could be a natural extension if all the formal credentialing requirements were met.

MTT: If you were a gambler, what odds would you give medical tourism for acceptance in the U.S.?

JA: I view this as a trend that is going to continue to gain momentum. What I wouldn’t bet on is the pace at which it will happen. I think that the momentum is going to be continually pushed by the uninsured and the underinsured because the motivation exists within this population. That same motivation just doesn’t exist today in the employer-based market, so I believe the pace in that segment of the U.S. population will be slower.

MTT: Do you have any employers that have indicated they would like to get started July 1st?

JA: None that are that committed or are at that point of committing to a definite date. But we do have several customers that are actively talking about the concept.

SPOTLIGHT
Skip McGaughey

Skip McGaughey Open Health Tools Foundation

In early April the Open Health Tools (OHT) Foundation announced it was launching a collaborative effort between national health agencies, government-funded organizations, healthcare providers, international standards organizations, and numerous companies from the United States, Canada, Australia, and the United Kingdom to develop common healthcare IT tools.

The OHT’s mission is to accelerate the implementation of electronic health information interoperability and, thus, increase patient safety, improve the quality of care, and advance the access to electronic health records (EHR).

Medical Travel Today recently had the opportunity to talk with Skip McGaughey, executive director of OHT about the organization and their goals. The following is an excerpt from that conversation.

Medical Travel Today (MTT): Tell us a bit about where the idea for the Open Health Tools came from and your involvement.

Skip McGaughey (SM): It evolved over the past 2-1/2 years and is really an outgrowth of lessons we’ve learned from the multiple organizations that our founding members have worked with over the years. We saw this as an opportunity to take advantage of the victories and beneficial things we’ve learned from other experiences and a way for us to not repeat mistakes.

At the start of this, you had a number of national organizations all sort of struggling to develop a way to handle their information. We recognized that there really was no need to keep recreating the same code over and over again around the world. So we decided to simply collaborate on building the same infrastructure code.

At that point we really formalized OHT and used the Eclipse Foundation as our model.

For your readers who may not be familiar with it, the Eclipse Foundation is a non-profit, member-support corporation that hosts the Eclipse projects. Eclipse is an open source community in the area of computer programming. It’s essentially a large and very vibrant community of individuals, corporations, academic institutions, and so forth, all who contribute ideas and means for building, expanding, and maintaining software across different platforms.

The Foundation offers some structure to all those individuals out there who are involved in the process.

The OHT is essentially the same. We provide some structure and guidance to the various entities and individuals who are attempting to increase interoperability of Health Information.

MTT: So does a hospital or company need to join OHT to participate?

SM: No, anyone can download the code and use it. Organizations can join OHT and participate in the planning and policies. It’s not complicated nor is there a fee. Any one, that includes individuals or organizations, with an interest in what we’re doing and an ability to contribute is welcome to join the open source community. Again, there’s no membership charge but we do look for a statement of what each member feels they can contribute. That could be working on a particular assignments, software development and input, helping with public relations or supporting an event, and so forth. We’re really looking for people and organizations who want to help to have secure health information when needed and where needed

MTT: How many members do you have at this time?

SM: We’re currently at 30. We anticipate growing at about eight new member organizations per quarter.

MTT: You mentioned assignments for members. Where exactly do those come from?

SM: Similar to Eclipse, we have a Board of Stewards. This group establishes what’s to be done, how it’s to be done, and establishes the constraints and functionality of each project. The Board meets once a quarter and reviews each project. We look at what’s being done with an eye towards accountability, success and risks. Ultimately we’re looking to make sure that projects are moving forward. From those meetings we provide direction back to the members on where to take something or how far to go. All the projects or assignments are about generating code to move things forward.

For example, in the UK the National Health Service is leading a project to do messaging so that one hospital can communicate with another or to a physicians office. They are leading a world wide effort to develop and deploy the software.

Australia is leading another world wide effort on terminology. The goal is to have everyone using same the same term worldwide to convey the same condition or meaning.

And the outcome of all these projects is shared worldwide.

MTT: That’ all very exciting. I’m sure managing that many ideas and types of talent presents some challenges. What would you say is your biggest obstacle at the moment?

SM: Language. And I don’t even mean English versus French or what have you. I mean the fact that the people who do the technology speak in a language that’s different from what physicians understand. Then you’ve got physicians who speak differently than computer software people, yet we are trying to get them all to talk about the same thing.

So what happens is the technology people adapt technology to meet the needs of what they think the need is, when in fact the physician’s need is actually quite different from what they perceived.

It can be hard to get them to communicate. But the good news is that once they understand each other—you know, find that common language—it’s very easy to get them talking. They’re all interested in the same thing. We just have to make sure they understand each other before undertaking their various efforts.

MTT: Very interesting. Looking specifically at medical travel, how do you see what you’re doing impacting this industry?

SM: The ultimate global information-share is going to fundamentally change things in all aspects of healthcare. A lot more people are going to have access to a lot more information. Those people are in turn going to discover and share ideas related to it. People of like minds and thinking will discover each other across the ocean instead of down the hall.

We’ll see some significant cost reductions as simplified, standardized information will increase efficiencies. That will save money and save time.

The number of organizations participating will in doubt increase as we find more and more solutions and commonalities. People will want to be a part of that; to benefit from it.

You know I’ve been to Australia, the UK, Canada, Asia, all over – and everybody is focused on just trying to cope with what they have to do today. What’s going to happen is that we’re going to provide them with the tools to get the day-to-day done. There will be ways to keep them from having to do the same things over and over again. And it could come from the other side of the world. It’s very, very global yet single-minded in focus.

But thinking past the software and code, the real opportunity is how to help save lives and how to improve the quality of care worldwide. That’s the real driving force.

About Skip McGaughey
As Executive Director of Open-Health Tools, Skip McGaughey focuses on healthcare open-source technology and worldwide deployment of software development tools. Previously, Skip was Chairman of the Eclipse Foundation, on assignment from IBM Corporation, his responsibility includes governance, membership recruitment and liaison between supporting member companies.

Prior to joining IBM, and following a teaching career at the University of North Carolina, Chapel Hill, Skip McGaughey was the data processing manager for a large information technology organization delivering human services in North Carolina.

To learn more about Open Health Tools visit www.openhealthtools.org.

 

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INDUSTRY NEWS

Your Medical Travel Newsletter Launched
Sponsorship Opportunities Available

This week CPR Strategic Marketing and Communications, publishers of Medical Travel Today, launched a new consumer-directed newsletter: Your Medical Travel: Travel Companion and News for Medical Tourists.

America’s first newsletter for the medical traveler, this monthly newsletter offers readers much-needed information on topics related to medical travel. Each issue deals with subjects ranging from choosing a destination and specialist to understanding your treatment options, arranging aftercare from your domestic provider, recognizing matters related to costs, insurance options, and the unique legal liabilities of this type of medical care.

Your Medical Travel: Travel Companion and News for Medical Tourists is free to consumers. To activate your subscription, simply email editor@yourmedicaltravel.com.

To learn more about sponsorship, email editor@yourmedicaltravel.com.

 

Now Available: BridgeHealth Interview with Employee Benefits Adviser

Medical tourism company BridgeHealth recently announced their global provider network, which appears to vary geographically as well as by the facilities' specialty services. Victor Lazzaro, BridgeHealth CEO, explains the role a strong network plays in creating confidence in care abroad and sheds light on the provider selection process.

To listen to the interview click here.

 

Publisher of Medical Travel Today Addresses Council for Affordable Health Insurance

On April 15, 2008 and at the invitation of Merrill Matthews, president, Council for Affordable Health Insurance, Medical Travel Today’s publisher Laura Carabello provided information about medical travel to a diverse audience of industry professionals.

Much of the discussion revolved around issues related to price. The following is an excerpt of the transcript from the Q&A portion of the event:

Laura Carabello (LC): I think one of the great things about medical tourism is the transparency of pricing as compared to what goes on in the US where there is still a lack of transparency. And, yes, people are shopping on the Internet. They may say, “I know I need a hip replacement and I’m going to look at Singapore, India and New Zealand.” And the answer is “Yes, you can get the pricing right up front and do your shopping on line.”

Medical tourism companies and coordinators in the United States such as BridgeHealth International might be able to guide you. But I think that people should be able to understand that the location, the safety and the accreditation and all such matters impacting quality are more important than the pricing. It’s going to be a lower price no matter what.

Merrill Matthews (MM): Is there is there some sort of body that approves the various medical tourism organizations? I expect that if this takes off, and this may already be the case, that there would be scam organizations popping up. So is there some way to accredit organizations?

LC: There is an organization that’s beginning to offer accreditation to medical travel coordinators. I can tell you there are a handful that are reliable groups that really do their homework. StarHospitals.net, for example, is run by physicians out of Canada, although they are starting to serve American medical tourists. BridgeHealth and MedRetreat are also names that come to mind. There is an accreditation body but I don’t know how much traction it’s gotten because it was recently announced.

Audience Participant: I am curious about how the hospitals are able to offer such low prices. I certainly understand the low labor and construction costs, but what about the equipment? Most top-of-the-line medical equipment is made in the United States, particularly imaging equipment. Do Indian providers get a better price from GE than American providers? Is there any of edge there that allows them to sell for less?

LC: I visited a hospital in Monterrey, Mexico over the summer and when I went into their imaging department I saw their MRI and CT scan equipment. They had a six-slice scanner and I was amazed to see that it was a GE piece of equipment. The fellow who was providing the tour for me said, “You know we get our equipment at a fraction of the cost of what they sell it to you in the United States.”

So the answer is yes, they are getting better deals. I don’t know how much of a better deal, but they are getting better deals. Going back to other costs, the big issue is, of course, malpractice. Patients really don’t have recourse with malpractice when they go to a place like India. So if you eliminate the cost of malpractice, all of a sudden it brings your cost way down.

Audience Participant: Do you have or do you expect to be able to generate statistics to be able to tell what the impact of medical malpractice insurance costs is on the cost of treatment in this country as opposed to those countries?

LC: That’s a great question. I don’t even know if the hospitals abroad even care to even do that calculation, so it’s going to be incumbent upon US providers to calculate those costs and to bring it to the fore. The foreign countries are obviously delighted that they don’t have these expenses.

.
Audience Participant: We have a bill in California coming up to prevent physicians from owning their own specialty hospitals in the US. Are you seeing or do you think we will see American surgeons not only investing and having a stake in overseas hospitals, but themselves commuting?

LC: It’s already happening. I spoke to the cardiovascular department at Baylor and that’s exactly what they do. For example, the hospitals in New Zealand and Argentina are owned by private physicians. They get the physicians from the United States to come down and do their procedures and then return home.

So this is becoming a very big option for physicians as well as patients. If they can provide the pre- and post-operative care and just do the procedures in a hospital, lets say in India or in Singapore -- which is a very safe place to be -- it’s great for them. They get a vacation out of it.

When I was in Monterrey, I interviewed a number of doctors who said ‘Hey listen -- I can make $350,000 down here and live like an absolute king. I don’t have to worry about managed care, I don’t have to worry about malpractice.” One orthopedist told me it was a no-brainer to relocate to Mexico.

Audience Participant: Can you talk a little more about the liability issues related to offering incentives to employees -- the extent to which there is case law in place or is this more of an unrealized concern?

LC: I think the employers have been very slow to get into this and with all the talk on how the industry is growing, the fact of the matter is that you have a handful if that, currently offering the benefit it.

It’s not thousands of people traveling as a result of their employers sending them. What I have been seeing is that employers are weighing their fiduciary responsibilities. There are some legal scholars, for example, that say if an employer sponsors a health plan offering workers a financial incentive to travel abroad, they could have greater liability risks. The concern is that the financial incentive might induce the employees to accept sub-standard care when they might have otherwise selected a local hospital.

I think a lot of this is still to be determined, still under exploration. I notice that the major law firms in America are just grabbing on to this, as not only an opportunity for them, but frankly for their customers. You have Epstein Becker really taking front and center in this whole medical tourism industry. McGuireWoods LLP, too. You have numerous law firms looking at this, so I think you have the best legal minds in the country now examining this and advising employers.

It’s not holding employers back from getting started but I think we are going to wait to see what the legal community advises. Hannaford said if they send two people this year they would be thrilled because those two surgeries alone would save them a ton of money.

MM: You mentioned that Blue Cross [Blue Shield] of South Carolina has gotten involved in this. Are there any other insurers involved?

LC: Well Blue Cross is the most prominent one, and David Boucher has been very vocal in expressing himself to the media. I have been interviewing numerous health plans and I can tell you that it’s a likely roll out with a number of them. Aetna is Hannaford’s carrier, so they are already involved in it. Cigna is obvious and I understand United has a big initiative underway, so I think you are going to see in 2009 a tremendous uptake in plans offering a medical travel benefit.

Now that doesn’t mean that it is going to generate thousands of patients right off the bat from the employers. But I think you are going to start to see it taking hold as a benefit option in the next six months or so. Americans will be incentivized financially by lower out-of-pocket costs or no out-of-pocket costs. That’s what Hannaford is doing—eliminating out-of-pocket costs. If you take somebody who has never left the state of Vermont – someone who has been a worker all of his or her life at a grocery store -- the idea of having a full paid trip to a foreign country is very intoxicating.

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WHAT YOU’RE READING

Healthy Travel Media Announces Second Edition of Patients Beyond Borders

Healthy Travel Media, publishers of Patients Beyond Borders: Everybody’s Guide to Affordable, World-Class Medical Tourism, recently announced that the second edition of its best-selling title will be released in July 2008. Even before publication, the book is receiving a great deal of attention for its comprehensive coverage and new data.

According to the book's author, Josef Woodman, “We’re particularly excited about the addition of several new destinations and the inclusion of what we feel is the most comprehensive cost-comparison data available to date.”

The Patients Beyond Borders cost comparison data will debut in the May 6, 2008 issue of U.S. News and World Report. The chart below offers readers an at-a-glance view of how various destinations compare on straight costs for specific procedures.

"In our research for the second edition, we sent surveys to hundred of hospitals all over the world," says Faith Brynie, editorial director of the Patients Beyond Borders series. "We compiled the information they returned with data sources published on Web sites, in technical and trade journals, and in consumer periodicals, to arrive at the best possible estimates of comparative costs."

Click chart to enlarge... These costs are for surgery (except as noted), including the hospital stay in a private, single-bed room. Airfare and lodging costs are governed by individual preferences. To compute a ballpark estimate of total costs, add $5,000 for you and a companion, figuring coach airfare and hotel rooms averaging $150 per night. For example, a hip replacement in Bangkok, Thailand, would cost about $18,000, for an estimated savings of at least $15,000 compared to the US price. *Doctor’s fees not included. © 2008 Healthy Travel Media. No Duplication or Distribution without Permission

The new edition includes information on emerging destinations such as Jordan, Korea, Panama, the Philippines, Taiwan, and Turkey.

“Our goal is to provide consumers with an objective and complete look at their options for medical travel. Inclusion of these destinations was essential to that goal,” adds Woodman.

In addition, patients looking to travel to specific destinations will soon have five country-specific editions to choose from. With the upcoming releases of Patients Beyond Borders India (August 2008), Patients Beyond Borders Taiwan (August 2008), Patients Beyond Borders Singapore Second Edition (August 2008), Patients Beyond Borders Malaysia (September 2008), and Patients Beyond Borders Korea (November 2008), patients will have access to in-depth information on accredited hospitals, clinics, and specialty centers in a preferred destination.

Thel Patients Beyond Borders Orthopedic Edition is slated for release in 2009 and will feature 20 leading orthopedic “Centers of Excellence,” including eight spinal and neurosurgery centers and four sports medicine clinics.

About Healthy Travel Media

Healthy Travel Media, an independent imprint based in Chapel Hill, NC, publishes books on medical travel, treatment and wellness. Patients Beyond Borders is available at Amazon and bookstores everywhere, and is distributed to the retail trade by Publishers Group West.

For more information, please visit: http://www.patientsbeyondborders.com.

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DESTINATION

Costa Rica
By Robin Elsham
 
If Costa Rica's prospects for remaining a top medtourism destination were marketed like a security, the prospectus would need to warn: past performance is no guarantee of future success.
 
Costa Rica today is one of the world's best known and most successful medical tourism destinations. It's routinely featured in media stories about medical tourism, where the emphasis is as much on tourism as healthcare. The stories profile cosmetic surgery patients recuperating at hilltop "recovery retreats," with million-dollar views of the Costa Rican capital below. Or savvy shoppers flying to Costa Rica for a "dental vacation," one where the savings on a root canal and crown pay for a week of white-water rafting or sipping rum drinks on a beach.
 
Costa Rica owes it medical tourism pre-eminence to good fortune and a long head start. It's good fortune was to be blessed with stunning natural beauty—hundreds of miles of tropical beaches along two ocean coasts, and an interior studded with volcanoes and rainforests, coffee plantations and waterfalls. The country offers breathtaking sightseeing, as well as deep-sea fishing, rainforest canopy tours, scuba diving and lots of adventure travel options. That's made Costa Rica the perfect backdrop for stories about paying for idyllic holidays through savings on healthcare.
 
Costa Rica's long head start in creating a medical tourism industry, decades before the industry began to develop globally, also insured attention. Costa Rica has been home to dental clinics and cosmetic surgery centers catering to foreign patients since the 1970s. By the time Thailand, India, Singapore and other countries started trumpeting their appeal as discount body shops, Costa Rica had already developed a reputation for being the "Beverly Hills of Latin America."
 
In fact, Costa Rica benefited from the greater noteriety and fascination with medical tourism generated by the emergence of other destinations. That's made medical tourism less exotic. And as word spread, North Americans in particular have been drawn to Costa Rica. Last year, tourist arrivals to Costa Rica increased 13%—with more than two-thirds coming from Canada and the United States. Of course most came simply for fun and sun. But anecdotal evidence points to the number of medical tourists increasing as well. And this in a country where a University of Costa Rica study some years ago showed 15% of tourists coming primarily for medical care.
 
But is that sustainable?
 
Visit Costa Rica and there's certainly much activity geared toward ramping up. The country now has it's first JCI-accredited medical facility in Hospital Clinica Biblica, with another two facilities—CIMA Hospital and Hospital La Catolica—both claiming to be months away from accreditation. (JCI itself never comments.) This is the most significant new twist in the development of Costa Rica as a global medical travel destination. It's now more than a destination for cosmetic surgery and dental care. It's targeting hospital care, through facilities replete with everything required to offer world-class healthcare.
 
The dental and cosmetic surgery sectors are expanding too. Visit a premier Costa Rican dental clinic like Instituto Flikier de Rehabilitacion Oral, and in addition to seeing the top-notch facilities already in place for the use of seven specialists (orthodontists, endodontists, maxillofacial surgeons, etc), you see space awaiting a doubling of capacity. Visit one of the country's famed "surgical recovery retreats" like Che Tica, and as much as its six existing theme cabins (with names like Old Tucson, Interlachen, Bonanza and Santorini, for their architecture and atmosphere), your attention is drawn to all the construction underway. Two wheelchair-accessible lodgings are being built for medical travelers coming to Costa Rica for joint replacement and spinal surgery, in addition to tummy tucks and whole-mouth reconstruction. At Las Cumbres, an elevator between its three floors of guest rooms was being added for the same purpose.
 
The government is helping the process along by expanding airport capacity, and by giving a push to English-language education. The number of gates at Juan Santamaria International Airport, located 20 kilometers (12 miles) northwest of the capital San Jose, was recently increased by six, to 16. Since 2002, travelers have also been able to take direct flights to an international airport in Liberia, the gateway to Guanacaste, a province in northwestern Costa Rica that's home to many of the country's best known beach resorts. Hospital Biblica and CIMA both have plans to build new hospitals in Guanacaste to serve medical tourists. And by 2011, a new international airport is planned for Sierpe in the far south, the focus of development around the Osa Peninsula.
 
Costa Rica's appeal to medical travelers will always benefit from the country's highly developed tourist industry. Accommodation options are plentiful, spanning a wide
range of prices and styles. A traveler can stay at a Four Season's resort in Guanacaste, where the least expensive room can cost $1,000 a day, or at Hotel Petit Victoria, a fire hazard off Paseo de Colon in central San Jose with rooms for $20 a night. Transportation is cheap: it seldom costs more than a few bucks to get between any two points in San Jose where most healthcare facilities for foreigners are located. And food and drink is pretty cheap. A satisfying meal like arroz con camarones (stir-fried rice with prawns) costs just $5 at a soda, as traditional Costa Rican diners are called. Add another buck for a cold bottle of wonderful Bohemia-brand dark beer.
 
Americans don't need to even bother changing money. The greenback is accepted everywhere. (But this convenience comes at a cost. One usually saves a few percent by paying in colones, the local currency.)
 
On the traveler- and patient-experience side, two things really stand out about Costa Rica. For travelers, it’s the choice of exquisite small boutique hotels to stay at. These family-run inns with five to 20 rooms, often surrounded by lush gardens and sometimes offering hypnotic views of distant volcanoes, exist in San Jose and throughout the country. Rates begin as low as $50/night.
 
Costa Rica's famed surgical recovery retreats are an outgrowth of that same tourism tradition. Facilities like Las Cumbres and Le Mas, both located in the hills of Escuela, an upmarket northwestern suburb of San Jose, are small. Las Cumbres is built like a luxury home, with just 14 guest rooms over three stories. Each floor has large, living room-like common areas—the ground floor's opening onto a pool and patio area, the upper floors with picture windows overlooking the city far below. Le Mas has just seven guest cabins: each architecturally distinct and with outside sitting areas offering stirring views of the Central Valley below and Pico Blanco towering overhead. Medical tourists pay about $90 to $125 a night to stay at these recovery retreats, which offer nursing care seven days a week. Help with changing bandages and dressings, injections and taking showers, from trained medical personnel.
 
Costa Rica has followed this formula to early success in the global medical tourism industry. Whether it can maintain that pre-eminence depends, though, on if it can adapt to changing market conditions. The forces fueling the growth in medical tourism to Costa Rica over the past several years are now threats to Costa Rica. As the global medical tourism industry grows and matures, Costa Rica faces competition from more destinations, including cheaper destinations. And, from destinations better organized, and with greater resources, to market themselves to medical travelers.

Costa Rica so far has nothing like the government/industry consortiums that exist in Singapore and India to mount high-powered, well-coordinated marketing campaigns to promote those countries as healthcare destinations. And closer to home, its geographic appeal to North American medical tourists is under threat from bigger, even more conveniently located service providers in northern Mexico, and better-financed rivals in Panama.
 
The biggest threat of all, though, is domestic. It's widespread indifference to how developments beyond Costa Rica could in just years erode its standing in the global medical tourism market.
 
Over a six-day visit to Costa Rica in February, that perception was repeatedly driven home. I pondered it while wandering the halls of Hospital La Catolica, a facility with ambitions to attract foreign patients. It's just invested a bundle on extensive renovations. But the approach is pure Field of Dreams: build it, and they will come. It's difficult to find any staff who speak English, or anyone able to explain La Catolica's medtourism marketing plan.

Facilities like La Catolica would benefit from tutoring by Hospital Clinica Biblica, which does have one of the best international patient departments in the global medical travel industry. HCB's process for caring for foreign patients is truly seamless: from first contact to final discharge, Clinica Biblica is methodical in its approach to caring for foreign patients. But that recognition of what's needed hasn't filtered through to La Catolica, or other healthcare providers in Costa Rica.
 
Nor has the necessary understanding developed within the Costa Rican government. Brad Cook, the head of Clinica Biblica's international office, says the Costa Rican medical industry and government have discussed the need for a joint body to lead the way. But no organization exists yet.
 
The need to act was repeatedly evident to me at the airport the day I left Costa Rica. While other destinations are systematically reviewing every aspect of a medical traveler's journey to make it as patient-friendly as possible, the departure process at San Jose international airport was a mini-nightmare. Long lines and annoyances like removing shoes going through security are standard everywhere. But why does Costa Rica compound the hassle factor by requiring passengers to separately queue up to pay a $26 departure tax? (As done elsewhere, why isn't the fee collected from the airlines, who automatically include it in the ticket price?) Or why could I not check in using the same e-ticket and information used at five other stops on the same trip? And why in an airport filled with so many foreign travelers was it so difficult to find airport staff able to communicate in English?
 
Costa Rica needs to study what competing destinations are doing to make traveling there problem-free. In the process, it's certain to recognize other factors requiring attention if the country is to remain a top medical travel destination. Given growing competition, past performance is no guarantee of future success.

 
Robin Elsham is the managing director of Patients With Passports Corp., an international healthcare arranger based in St. Paul, Minnesota. He can be contacted at robin.elsham@patientswithpassports.com.