Erik Goldman

NEW YORK — Methicillin-resistant Staphylococcus aureus is now the most common cause of serious skin and soft-tissue infections in many communities throughout the United States, Dr. Mark Lebwohl said at the American Academy of Dermatology's annual Academy 2007 meeting.

"If you're getting cultures, you're seeing this, because it is definitely there," said Dr. Lebwohl of the department of dermatology at Mount Sinai Medical Center, New York. "Where's it coming from? Everywhere!"

In one study he cited, methicillin-resistant Staphylococcus aureus (MRSA) accounted for 72% of all skin and soft-tissue infections seen at a major medical center and affiliated outpatient clinics in Atlanta (Ann. Intern. Med. 2006;144:309–17). MRSA is particularly common among athletes, military personnel, homeless people, and intravenous drug users, but in reality, everyone is at risk, he stressed.

The bad news is that MRSA isn't just resistant to methicillin. It seems to be increasingly resistant to most antibiotics these days. "Unfortunately, vancomycin resistance is emerging in MRSA organisms. Erythromycin borders on worthless, as almost all MRSA strains are erythromycin-resistant," he said.

Clindamycin is still effective in most communities around the country, but resistance to this drug also is starting to show up. Between 10% and 15% of all MRSA strains identified in Atlanta, Minnesota, and Baltimore are resistant to clindamycin. In Chicago, the number is over 50% for infected adults, Dr. Lebwohl noted.

Fortunately, trimethoprim-sulfamethoxazole (Bactrim) continues to work almost everywhere. In Baltimore, though, 17% of MRSA strains have been found resistant to this drug as well.

All of this bad news might lead one to conclude that antibiotic therapy for MRSA is ultimately futile. A study published several years ago suggested that, when treating MRSA-infected skin and soft-tissue abscesses, there were no significant differences whatsoever between allegedly effective and ineffective antibiotics, and that the key to treatment was incision and drainage (Pediatr. Infect. Dis. J. 2004;23:123–7).

Dr. Lebwohl cautioned against such antibiotic nihilism. "If there's no difference between the antibiotics, it's reasonable to ask: Why treat? But the point is, it is not the patient you are seeing that you worry about. It is the person you are not seeing: the patient's family members, neighbors, colleagues. MRSA can cause sepsis, coagulopathy, osteomyelitis. It can kill people. It is very serious. You need to use the right antibiotics, because in treating your patient properly you are also treating the whole community."

Clindamycin and Bactrim are still good options, as are doxycycline and minocycline, although they are not recommended for children. For adults, doxycycline and minocycline are the top choices, he said. Daptomycin (Cubicin) is also a good choice for deep-tissue infections, especially in the bones and joints (Curr. Med. Res. Opin. 2005;21:1923–6).

Dr. Lebwohl also had high praise for linezolid (Zyvox), a newcomer to the antibiotic front lines. MRSA seems to be very sensitive to this drug: A recent in vitro study of almost 3,400 MRSA isolates showed that all were sensitive to linezolid (Antimicrob. Agents Chemother. 2005;49:5024–32). Unfortunately, it is very expensive.

Generally, one should stay clear of using quinolones and macrolides, because they are ineffective against MRSA at this point. Rifampin may seem to work at first, but resistance tends to develop very quickly.

Dr. Lebwohl strongly advised colleagues to read and practice according to the Infectious Diseases Society of America's 2005 guidelines for the management of skin and soft-tissue infections (Clin. Infect. Dis. 2005;41:1373–406).

He also advocated routine culture and sensitivity testing. The more information physicians can gather about the infections they are confronting, the more intelligently they can choose the antibiotic therapy.

Over the past year, Dr. Lebwohl has been a consultant for a number of drug companies, including Galderma (clindamycin) and Pfizer (doxycycline).

NEW YORK — Methicillin-resistant Staphylococcus aureus is now the most common cause of serious skin and soft-tissue infections in many communities throughout the United States, Dr. Mark Lebwohl said at the American Academy of Dermatology's annual Academy 2007 meeting.

"If you're getting cultures, you're seeing this, because it is definitely there," said Dr. Lebwohl of the department of dermatology at Mount Sinai Medical Center, New York. "Where's it coming from? Everywhere!"

In one study he cited, methicillin-resistant Staphylococcus aureus (MRSA) accounted for 72% of all skin and soft-tissue infections seen at a major medical center and affiliated outpatient clinics in Atlanta (Ann. Intern. Med. 2006;144:309–17). MRSA is particularly common among athletes, military personnel, homeless people, and intravenous drug users, but in reality, everyone is at risk, he stressed.

The bad news is that MRSA isn't just resistant to methicillin. It seems to be increasingly resistant to most antibiotics these days. "Unfortunately, vancomycin resistance is emerging in MRSA organisms. Erythromycin borders on worthless, as almost all MRSA strains are erythromycin-resistant," he said.

Clindamycin is still effective in most communities around the country, but resistance to this drug also is starting to show up. Between 10% and 15% of all MRSA strains identified in Atlanta, Minnesota, and Baltimore are resistant to clindamycin. In Chicago, the number is over 50% for infected adults, Dr. Lebwohl noted.

Fortunately, trimethoprim-sulfamethoxazole (Bactrim) continues to work almost everywhere. In Baltimore, though, 17% of MRSA strains have been found resistant to this drug as well.

All of this bad news might lead one to conclude that antibiotic therapy for MRSA is ultimately futile. A study published several years ago suggested that, when treating MRSA-infected skin and soft-tissue abscesses, there were no significant differences whatsoever between allegedly effective and ineffective antibiotics, and that the key to treatment was incision and drainage (Pediatr. Infect. Dis. J. 2004;23:123–7).

Dr. Lebwohl cautioned against such antibiotic nihilism. "If there's no difference between the antibiotics, it's reasonable to ask: Why treat? But the point is, it is not the patient you are seeing that you worry about. It is the person you are not seeing: the patient's family members, neighbors, colleagues. MRSA can cause sepsis, coagulopathy, osteomyelitis. It can kill people. It is very serious. You need to use the right antibiotics, because in treating your patient properly you are also treating the whole community."

Clindamycin and Bactrim are still good options, as are doxycycline and minocycline, although they are not recommended for children. For adults, doxycycline and minocycline are the top choices, he said. Daptomycin (Cubicin) is also a good choice for deep-tissue infections, especially in the bones and joints (Curr. Med. Res. Opin. 2005;21:1923–6).

Dr. Lebwohl also had high praise for linezolid (Zyvox), a newcomer to the antibiotic front lines. MRSA seems to be very sensitive to this drug: A recent in vitro study of almost 3,400 MRSA isolates showed that all were sensitive to linezolid (Antimicrob. Agents Chemother. 2005;49:5024–32). Unfortunately, it is very expensive.

Generally, one should stay clear of using quinolones and macrolides, because they are ineffective against MRSA at this point. Rifampin may seem to work at first, but resistance tends to develop very quickly.

Dr. Lebwohl strongly advised colleagues to read and practice according to the Infectious Diseases Society of America's 2005 guidelines for the management of skin and soft-tissue infections (Clin. Infect. Dis. 2005;41:1373–406).

He also advocated routine culture and sensitivity testing. The more information physicians can gather about the infections they are confronting, the more intelligently they can choose the antibiotic therapy.

Over the past year, Dr. Lebwohl has been a consultant for a number of drug companies, including Galderma (clindamycin) and Pfizer (doxycycline).

NEW YORK — Methicillin-resistant Staphylococcus aureus is now the most common cause of serious skin and soft-tissue infections in many communities throughout the United States, Dr. Mark Lebwohl said at the American Academy of Dermatology's annual Academy 2007 meeting.

"If you're getting cultures, you're seeing this, because it is definitely there," said Dr. Lebwohl of the department of dermatology at Mount Sinai Medical Center, New York. "Where's it coming from? Everywhere!"

In one study he cited, methicillin-resistant Staphylococcus aureus (MRSA) accounted for 72% of all skin and soft-tissue infections seen at a major medical center and affiliated outpatient clinics in Atlanta (Ann. Intern. Med. 2006;144:309–17). MRSA is particularly common among athletes, military personnel, homeless people, and intravenous drug users, but in reality, everyone is at risk, he stressed.

The bad news is that MRSA isn't just resistant to methicillin. It seems to be increasingly resistant to most antibiotics these days. "Unfortunately, vancomycin resistance is emerging in MRSA organisms. Erythromycin borders on worthless, as almost all MRSA strains are erythromycin-resistant," he said.

Clindamycin is still effective in most communities around the country, but resistance to this drug also is starting to show up. Between 10% and 15% of all MRSA strains identified in Atlanta, Minnesota, and Baltimore are resistant to clindamycin. In Chicago, the number is over 50% for infected adults, Dr. Lebwohl noted.

Fortunately, trimethoprim-sulfamethoxazole (Bactrim) continues to work almost everywhere. In Baltimore, though, 17% of MRSA strains have been found resistant to this drug as well.

All of this bad news might lead one to conclude that antibiotic therapy for MRSA is ultimately futile. A study published several years ago suggested that, when treating MRSA-infected skin and soft-tissue abscesses, there were no significant differences whatsoever between allegedly effective and ineffective antibiotics, and that the key to treatment was incision and drainage (Pediatr. Infect. Dis. J. 2004;23:123–7).

Dr. Lebwohl cautioned against such antibiotic nihilism. "If there's no difference between the antibiotics, it's reasonable to ask: Why treat? But the point is, it is not the patient you are seeing that you worry about. It is the person you are not seeing: the patient's family members, neighbors, colleagues. MRSA can cause sepsis, coagulopathy, osteomyelitis. It can kill people. It is very serious. You need to use the right antibiotics, because in treating your patient properly you are also treating the whole community."

Clindamycin and Bactrim are still good options, as are doxycycline and minocycline, although they are not recommended for children. For adults, doxycycline and minocycline are the top choices, he said. Daptomycin (Cubicin) is also a good choice for deep-tissue infections, especially in the bones and joints (Curr. Med. Res. Opin. 2005;21:1923–6).

Dr. Lebwohl also had high praise for linezolid (Zyvox), a newcomer to the antibiotic front lines. MRSA seems to be very sensitive to this drug: A recent in vitro study of almost 3,400 MRSA isolates showed that all were sensitive to linezolid (Antimicrob. Agents Chemother. 2005;49:5024–32). Unfortunately, it is very expensive.

Generally, one should stay clear of using quinolones and macrolides, because they are ineffective against MRSA at this point. Rifampin may seem to work at first, but resistance tends to develop very quickly.

Dr. Lebwohl strongly advised colleagues to read and practice according to the Infectious Diseases Society of America's 2005 guidelines for the management of skin and soft-tissue infections (Clin. Infect. Dis. 2005;41:1373–406).

He also advocated routine culture and sensitivity testing. The more information physicians can gather about the infections they are confronting, the more intelligently they can choose the antibiotic therapy.

Over the past year, Dr. Lebwohl has been a consultant for a number of drug companies, including Galderma (clindamycin) and Pfizer (doxycycline).

NEW YORK — Is Gleevec a reasonable therapeutic choice for melanoma?

The question has gotten a fair bit of research attention over the last few years, and for a few specific types of melanoma the outlook is cautiously optimistic, Dr. Philip LeBoit said at the American Academy of Dermatology's summer academy 2007 conference.

Gleevec (imatinib mesylate) will probably not become a first-line therapy for cutaneous melanoma, but it may work for mucosal melanomas, acral melanomas, and others that share genetic similarities to the sort of gastrointestinal lesions that have been highly responsive to this landmark drug. A number of case reports point in this direction, said Dr. LeBoit of the departments of pathology and dermatology at the University of California, San Francisco.

Gleevec was the breakthrough agent representing a class of drugs that target protein tyrosine kinase (PTK), an enzyme that plays an essential role in the proliferation and migration of many kinds of cancer cells. Gleevec-responsive tumors tend to have specific genetic profiles, showing mutations of the c-kit and abl genes, among others.

The drug has been particularly effective against GI stromal tumors, which have distinct c-kit mutations. The good news is that as dermatopathologists and molecular biologists explore genetic profiles of various kinds of skin cancers, they are finding that some melanoma types, especially mucosal melanomas, share these c-kit mutations, said Dr. LeBoit, who has no financial relationship with Novartis, the manufacturer of Gleevec.

"Mucosal melanomas have a lot of c-kit mutations. These tumors are almost impossible to resect. They may be candidates for Gleevec or second-generation drugs of that class," he said. Most mucosal melanomas are positive for c-kit mutations, as are roughly one-third of all cutaneous melanomas.

Dermatopathologists at the M.D. Anderson Cancer Center, Houston, studied before- and after-treatment biopsy specimens from 13 patients with malignant melanoma who were given Gleevec at a dose of 400 mg twice daily for 2 weeks. The drug produced a significant decrease in PTK expression in the tumor tissue, as well as a reduction in the number of malignant melanocytes and the intensity of their proliferation (J. Cutan. Pathol. 2006;33:280–5). The investigators noted that one of the 13 patients showed a "durable clinical response."

Brazilian researchers looked at the impact of Gleevec in tissue samples from uveal melanomas, the most common intraocular form of melanoma. Nearly 80% of the 55 tumors examined were positive for c-kit mutations. Gleevec reduced proliferation of the tumor cells in culture (J. Carcinog. 2005;4:19).

A recent phase II trial, however, showed little clinical impact from Gleevec therapy for cutaneous melanomas (Cancer 2006;106:2005–11).

Dr. Lynn Schuchter of the University of Pennsylvania, Philadelphia, is currently studying Gleevec in combination with temozolomide in 63 patients with advanced melanoma, Dr. LeBoit said. So far, the toxicity profile suggests that the PTK inhibitor is a viable adjunct with no significant added side-effect burden. Clinical outcomes data are not yet available.

It may be that Gleevec only works in tumors with very specific genetic profiles, and the key is to identify tumor susceptibility before treatment, in a way analogous to antibiotic susceptibility testing for microbial pathogens. This, said Dr. LeBoit, is the general trend in cancer therapy: the application of tools like immunohistochemistry and comparative genomic hybridization to subclassify tumors based on their genetic features.

"Cancer is fundamentally a disease of the genome. Something has to be wrong with the cells' DNA. Most cancer cells have gains or losses of whole chromosomes or major parts of chromosomes," he noted.

A few years ago, dermatopathologists were dependent almost exclusively on microscopy because there simply were no practical molecular diagnostic tools, but that scenario is changing fast. Diagnosis of skin cancers like melanoma "is not a simple positive-or-negative, yes-or-no process. We really need to get into the nuclei of cells to see what is going on," Dr. LeBoit said.

NEW YORK — Is Gleevec a reasonable therapeutic choice for melanoma?

The question has gotten a fair bit of research attention over the last few years, and for a few specific types of melanoma the outlook is cautiously optimistic, Dr. Philip LeBoit said at the American Academy of Dermatology's summer academy 2007 conference.

Gleevec (imatinib mesylate) will probably not become a first-line therapy for cutaneous melanoma, but it may work for mucosal melanomas, acral melanomas, and others that share genetic similarities to the sort of gastrointestinal lesions that have been highly responsive to this landmark drug. A number of case reports point in this direction, said Dr. LeBoit of the departments of pathology and dermatology at the University of California, San Francisco.

Gleevec was the breakthrough agent representing a class of drugs that target protein tyrosine kinase (PTK), an enzyme that plays an essential role in the proliferation and migration of many kinds of cancer cells. Gleevec-responsive tumors tend to have specific genetic profiles, showing mutations of the c-kit and abl genes, among others.

The drug has been particularly effective against GI stromal tumors, which have distinct c-kit mutations. The good news is that as dermatopathologists and molecular biologists explore genetic profiles of various kinds of skin cancers, they are finding that some melanoma types, especially mucosal melanomas, share these c-kit mutations, said Dr. LeBoit, who has no financial relationship with Novartis, the manufacturer of Gleevec.

"Mucosal melanomas have a lot of c-kit mutations. These tumors are almost impossible to resect. They may be candidates for Gleevec or second-generation drugs of that class," he said. Most mucosal melanomas are positive for c-kit mutations, as are roughly one-third of all cutaneous melanomas.

Dermatopathologists at the M.D. Anderson Cancer Center, Houston, studied before- and after-treatment biopsy specimens from 13 patients with malignant melanoma who were given Gleevec at a dose of 400 mg twice daily for 2 weeks. The drug produced a significant decrease in PTK expression in the tumor tissue, as well as a reduction in the number of malignant melanocytes and the intensity of their proliferation (J. Cutan. Pathol. 2006;33:280–5). The investigators noted that one of the 13 patients showed a "durable clinical response."

Brazilian researchers looked at the impact of Gleevec in tissue samples from uveal melanomas, the most common intraocular form of melanoma. Nearly 80% of the 55 tumors examined were positive for c-kit mutations. Gleevec reduced proliferation of the tumor cells in culture (J. Carcinog. 2005;4:19).

A recent phase II trial, however, showed little clinical impact from Gleevec therapy for cutaneous melanomas (Cancer 2006;106:2005–11).

Dr. Lynn Schuchter of the University of Pennsylvania, Philadelphia, is currently studying Gleevec in combination with temozolomide in 63 patients with advanced melanoma, Dr. LeBoit said. So far, the toxicity profile suggests that the PTK inhibitor is a viable adjunct with no significant added side-effect burden. Clinical outcomes data are not yet available.

It may be that Gleevec only works in tumors with very specific genetic profiles, and the key is to identify tumor susceptibility before treatment, in a way analogous to antibiotic susceptibility testing for microbial pathogens. This, said Dr. LeBoit, is the general trend in cancer therapy: the application of tools like immunohistochemistry and comparative genomic hybridization to subclassify tumors based on their genetic features.

"Cancer is fundamentally a disease of the genome. Something has to be wrong with the cells' DNA. Most cancer cells have gains or losses of whole chromosomes or major parts of chromosomes," he noted.

A few years ago, dermatopathologists were dependent almost exclusively on microscopy because there simply were no practical molecular diagnostic tools, but that scenario is changing fast. Diagnosis of skin cancers like melanoma "is not a simple positive-or-negative, yes-or-no process. We really need to get into the nuclei of cells to see what is going on," Dr. LeBoit said.

NEW YORK — Is Gleevec a reasonable therapeutic choice for melanoma?

The question has gotten a fair bit of research attention over the last few years, and for a few specific types of melanoma the outlook is cautiously optimistic, Dr. Philip LeBoit said at the American Academy of Dermatology's summer academy 2007 conference.

Gleevec (imatinib mesylate) will probably not become a first-line therapy for cutaneous melanoma, but it may work for mucosal melanomas, acral melanomas, and others that share genetic similarities to the sort of gastrointestinal lesions that have been highly responsive to this landmark drug. A number of case reports point in this direction, said Dr. LeBoit of the departments of pathology and dermatology at the University of California, San Francisco.

Gleevec was the breakthrough agent representing a class of drugs that target protein tyrosine kinase (PTK), an enzyme that plays an essential role in the proliferation and migration of many kinds of cancer cells. Gleevec-responsive tumors tend to have specific genetic profiles, showing mutations of the c-kit and abl genes, among others.

The drug has been particularly effective against GI stromal tumors, which have distinct c-kit mutations. The good news is that as dermatopathologists and molecular biologists explore genetic profiles of various kinds of skin cancers, they are finding that some melanoma types, especially mucosal melanomas, share these c-kit mutations, said Dr. LeBoit, who has no financial relationship with Novartis, the manufacturer of Gleevec.

"Mucosal melanomas have a lot of c-kit mutations. These tumors are almost impossible to resect. They may be candidates for Gleevec or second-generation drugs of that class," he said. Most mucosal melanomas are positive for c-kit mutations, as are roughly one-third of all cutaneous melanomas.

Dermatopathologists at the M.D. Anderson Cancer Center, Houston, studied before- and after-treatment biopsy specimens from 13 patients with malignant melanoma who were given Gleevec at a dose of 400 mg twice daily for 2 weeks. The drug produced a significant decrease in PTK expression in the tumor tissue, as well as a reduction in the number of malignant melanocytes and the intensity of their proliferation (J. Cutan. Pathol. 2006;33:280–5). The investigators noted that one of the 13 patients showed a "durable clinical response."

Brazilian researchers looked at the impact of Gleevec in tissue samples from uveal melanomas, the most common intraocular form of melanoma. Nearly 80% of the 55 tumors examined were positive for c-kit mutations. Gleevec reduced proliferation of the tumor cells in culture (J. Carcinog. 2005;4:19).

A recent phase II trial, however, showed little clinical impact from Gleevec therapy for cutaneous melanomas (Cancer 2006;106:2005–11).

Dr. Lynn Schuchter of the University of Pennsylvania, Philadelphia, is currently studying Gleevec in combination with temozolomide in 63 patients with advanced melanoma, Dr. LeBoit said. So far, the toxicity profile suggests that the PTK inhibitor is a viable adjunct with no significant added side-effect burden. Clinical outcomes data are not yet available.

It may be that Gleevec only works in tumors with very specific genetic profiles, and the key is to identify tumor susceptibility before treatment, in a way analogous to antibiotic susceptibility testing for microbial pathogens. This, said Dr. LeBoit, is the general trend in cancer therapy: the application of tools like immunohistochemistry and comparative genomic hybridization to subclassify tumors based on their genetic features.

"Cancer is fundamentally a disease of the genome. Something has to be wrong with the cells' DNA. Most cancer cells have gains or losses of whole chromosomes or major parts of chromosomes," he noted.

A few years ago, dermatopathologists were dependent almost exclusively on microscopy because there simply were no practical molecular diagnostic tools, but that scenario is changing fast. Diagnosis of skin cancers like melanoma "is not a simple positive-or-negative, yes-or-no process. We really need to get into the nuclei of cells to see what is going on," Dr. LeBoit said.

WASHINGTON — If you're of the mind that the pay-for-performance plans instituted by federal as well as private payers are questionable at best and potentially dangerous at worst, don't worry: you're not alone. Many of the leaders of the pay-for-performance movement share those concerns.

Speaking at the fourth World Health Care Congress, advocates of pay-for-performance (P4P) acknowledged that if not designed carefully, these plans can create perverse incentives, warp physician behavior, and ultimately fail in their primary objective of improving health care quality.

P4P leaders admit that in many cases, they're not sure they're tracking the right measures. Even if they do get it right, there is little evidence that the measures are truly meaningful to ordinary people needing to make medical decisions.

This doesn't mean P4P is going away any time soon. In fact, P4P plans will only become more widespread in the coming years, spurred on by Medicare's embrace of the concept. But P4P advocates are rapidly finding out they need to assess the impact of their systems as closely as they monitor physician and hospital performance.

“Everything we do must be monitored for unintended consequences. P4P plans are no different. The movement is in its infancy,” said Dr. Tom Valuck, director of value-based purchasing for the Centers for Medicare and Medicaid Services. He cited a recent Institute of Medicine report concluding that while P4P has potential to improve health care systems, experience is still very limited, close monitoring is essential, and plan developers need to build in provisions for rapid redesign and correction.

“P4P may lead to focus on wrong priorities. For example, we can end up focusing on individual accountability instead of system performance. This raises a lot of questions about rewards and incentives.” Wrongly focused P4P could exacerbate health care disparities, leading to cherry-picking and cream-skimming, and detracting clinical attention from other priorities, he added. “We may end up teaching to the test, while ignoring the bigger picture.”

Dr. Brent James is executive director of the Institute for Healthcare Delivery Research at Intermountain Healthcare, a health system with one of the most proactive quality improvement and performance measurement systems in the nation. An early advocate of P4P, Dr. James said he has learned some important lessons over several attempts at establishing P4P programs.

Where most P4P plans go awry is by being overly focused on arbitrarily-chosen individual physician “accountability” measures and not being focused enough on overall systems process measures that tie back to meaningful clinical outcomes, said Dr. James.

“You have to show end-of-day improvement in care. If everyone is doing 'perfect score' medicine, but there's no improvement in outcomes, it means either people are gaming the system or the measures are irrelevant. If you build for system improvement, you'll get accountability data along the way. Build from the bottom up, so as not to damage care.”

Dr. James defines systems transparency as meaning “you have sufficient information to make a whole series of decisions, and this holds for patients and practitioners alike. It is not as if any one single piece of information tells the whole story or allows one to make a definitive decision. Transparency is a much broader, a much more profound concept than accountability.”

Dr. James said that he is wary of plans that attach heavy financial rewards or penalties to individual physician measures. First, the measures may not be clinically important ones, and may end up rewarding “performance” on tasks that do not really lead to better patient care. Secondly, financial incentives can skew care delivery. “As you attach greater rewards or punishments to achieving a number, you get increasing propensity for suboptimization; you make one area look good at the expense of the others.”

Finally, financial incentives create the wrong sort of motivations. “One of the worst things you can do to physicians is tell them that money is more important than their professional judgment. They will end up believing you,” he said.

An effective P4P program motivates physicians by stressing improved patient care. “Extrinsic awards destroy intrinsic motivation for improvement. Get the professional incentives right and you get system improvement,” said Dr. James.

Tom Sackville, chief executive of International Federation of Health Plans, and former Minister of Health in Britain, strongly agreed. “Doctors are highly trained, independent-minded, intelligent professionals. They know what they have to do. If they perceive distant bureaucrats throwing bits of fish, they'll start behaving like … performing sea lions. Our doctors pride themselves on having a true vocation. We spoil that at our peril.”

“The things that people measure in P4P are dictated by ivory tower thinkers. Their relevance to patients, or even to the administrative process, is very questionable,” said Robert Burney, director of Quality Improvement for the U.S. Department of State.

Dr. James questioned the extent to which P4P data has any relevance to patients at all. “The truth is patients really do not use outcomes statistics to make their health care decisions. They rely on stories, based on relationships. They'll tell you they want data, but when we measure decision making, the data do not drive it. We have several good studies of this topic, where they gave patients carefully prepared statistics. Patients say the stats changed their decisions, but when we look closely, people do not change decisions based on data. Humans are more emotional than statistical.”

If patients tend not to respond to data, physicians will … eventually.

Dr. Varga said doctors tend to go through “a sort of 'Kübler-Ross acceptance process'” when it comes to P4P, going from a denial attitude of, “Your data stinks, its all BS,” through one of, “Your data are meaningful but don't really apply to me,” through, “The reason my data are bad is because everyone's data are bad,” to finally accepting there's a need for improvement. But that's provided a P4P system is truly oriented toward system-wide care improvement and not simply punitive toward individuals.

Punitive ranking systems can have a very detrimental effect on health care, said several experts at the conference. On an individual level, P4P may favor older, more experienced practitioners at the expense of younger ones who may have less experience with a given procedure, and thus may get labeled early on in their careers as “lower quality.” This can make it hard for younger doctors to build practices.

There's also a very real danger, said Dr. Varga, of putting smaller rural practices out of business if Medicare reimbursement is overly tied to rigid performance measures. “You can end up destroying health care delivery for small rural counties. A lot of smaller rural hospitals are working on very small margins. If you take away 5% of their Medicare revenue, they close their doors. They can't take that kind of hit.”

At its best, P4P is a set of tools for improving health care outcomes, reducing iatrogenic illness and adverse events, and improving the overall return on every health care dollar spent. Advocates believe that with the right measures, P4P can achieve these goals.

“I think doctors are motivated to improve if they see objective data that they are not performing as well as their peers. It is not necessarily a financial incentive, but a patient care incentive that will motivate them,” said Dr. Jack Lewin, CEO of the American College of Cardiology. ACC has developed a vigorous program of accountability guidelines aimed at improving the quality of cardiovascular care.

“Ultimately, we want to show individual cardiologists how they are doing in relation to their peers on real world indicators, and we want to give them tools for improvement.” Given that cardiovascular disease consumes over 43% of total health care dollars, a little improvement will go a long way, said Dr. Lewin.

ACC is currently studying “door to balloon” time at major centers, in an effort to reduce the interval from when a patient arrives at a hospital until he or she is in the angioplasty suite. “How fast do the best hospitals get you from the e-room door to the balloon angioplasty? You want this to happen within 90 minutes.”

The National Cardiovascular Data Registries, which ACC supports, represent a major national project aimed at tracking hospital performance on a wide range of procedures including immediate response to acute MI, balloon angioplasty, and implantation of defibrillators. Data are being gathered in roughly 2,300 centers around the country.

“We can tell the medical staff how they are doing compared to their peers,” Dr. Lewin said at the conference, which was sponsored by the Wall Street Journal and CNBC. “We still need the patient outcomes side, but the program is underway, and some states mandate that hospitals participate if they want the states' Medicare and Medicaid data.”

Dr. Peter Angood, codirector of the Joint Commission International's Center for Patient Safety, likened current quality improvement efforts, flawed though they may be, to the airline industry's efforts to improve safety performance.

“It took the aviation industry 40-45 years to improve performance quality and really get continuous quality improvement in place. In health care, we're just passing the stage where we acknowledge there's a problem. How do we compress that 40-year curve down to just one generation?” Dr. Angood asked.

WASHINGTON — If you're of the mind that the pay-for-performance plans instituted by federal as well as private payers are questionable at best and potentially dangerous at worst, don't worry: you're not alone. Many of the leaders of the pay-for-performance movement share those concerns.

Speaking at the fourth World Health Care Congress, advocates of pay-for-performance (P4P) acknowledged that if not designed carefully, these plans can create perverse incentives, warp physician behavior, and ultimately fail in their primary objective of improving health care quality.

P4P leaders admit that in many cases, they're not sure they're tracking the right measures. Even if they do get it right, there is little evidence that the measures are truly meaningful to ordinary people needing to make medical decisions.

This doesn't mean P4P is going away any time soon. In fact, P4P plans will only become more widespread in the coming years, spurred on by Medicare's embrace of the concept. But P4P advocates are rapidly finding out they need to assess the impact of their systems as closely as they monitor physician and hospital performance.

“Everything we do must be monitored for unintended consequences. P4P plans are no different. The movement is in its infancy,” said Dr. Tom Valuck, director of value-based purchasing for the Centers for Medicare and Medicaid Services. He cited a recent Institute of Medicine report concluding that while P4P has potential to improve health care systems, experience is still very limited, close monitoring is essential, and plan developers need to build in provisions for rapid redesign and correction.

“P4P may lead to focus on wrong priorities. For example, we can end up focusing on individual accountability instead of system performance. This raises a lot of questions about rewards and incentives.” Wrongly focused P4P could exacerbate health care disparities, leading to cherry-picking and cream-skimming, and detracting clinical attention from other priorities, he added. “We may end up teaching to the test, while ignoring the bigger picture.”

Dr. Brent James is executive director of the Institute for Healthcare Delivery Research at Intermountain Healthcare, a health system with one of the most proactive quality improvement and performance measurement systems in the nation. An early advocate of P4P, Dr. James said he has learned some important lessons over several attempts at establishing P4P programs.

Where most P4P plans go awry is by being overly focused on arbitrarily-chosen individual physician “accountability” measures and not being focused enough on overall systems process measures that tie back to meaningful clinical outcomes, said Dr. James.

“You have to show end-of-day improvement in care. If everyone is doing 'perfect score' medicine, but there's no improvement in outcomes, it means either people are gaming the system or the measures are irrelevant. If you build for system improvement, you'll get accountability data along the way. Build from the bottom up, so as not to damage care.”

Dr. James defines systems transparency as meaning “you have sufficient information to make a whole series of decisions, and this holds for patients and practitioners alike. It is not as if any one single piece of information tells the whole story or allows one to make a definitive decision. Transparency is a much broader, a much more profound concept than accountability.”

Dr. James said that he is wary of plans that attach heavy financial rewards or penalties to individual physician measures. First, the measures may not be clinically important ones, and may end up rewarding “performance” on tasks that do not really lead to better patient care. Secondly, financial incentives can skew care delivery. “As you attach greater rewards or punishments to achieving a number, you get increasing propensity for suboptimization; you make one area look good at the expense of the others.”

Finally, financial incentives create the wrong sort of motivations. “One of the worst things you can do to physicians is tell them that money is more important than their professional judgment. They will end up believing you,” he said.

An effective P4P program motivates physicians by stressing improved patient care. “Extrinsic awards destroy intrinsic motivation for improvement. Get the professional incentives right and you get system improvement,” said Dr. James.

Tom Sackville, chief executive of International Federation of Health Plans, and former Minister of Health in Britain, strongly agreed. “Doctors are highly trained, independent-minded, intelligent professionals. They know what they have to do. If they perceive distant bureaucrats throwing bits of fish, they'll start behaving like … performing sea lions. Our doctors pride themselves on having a true vocation. We spoil that at our peril.”

“The things that people measure in P4P are dictated by ivory tower thinkers. Their relevance to patients, or even to the administrative process, is very questionable,” said Robert Burney, director of Quality Improvement for the U.S. Department of State.

Dr. James questioned the extent to which P4P data has any relevance to patients at all. “The truth is patients really do not use outcomes statistics to make their health care decisions. They rely on stories, based on relationships. They'll tell you they want data, but when we measure decision making, the data do not drive it. We have several good studies of this topic, where they gave patients carefully prepared statistics. Patients say the stats changed their decisions, but when we look closely, people do not change decisions based on data. Humans are more emotional than statistical.”

If patients tend not to respond to data, physicians will … eventually.

Dr. Varga said doctors tend to go through “a sort of 'Kübler-Ross acceptance process'” when it comes to P4P, going from a denial attitude of, “Your data stinks, its all BS,” through one of, “Your data are meaningful but don't really apply to me,” through, “The reason my data are bad is because everyone's data are bad,” to finally accepting there's a need for improvement. But that's provided a P4P system is truly oriented toward system-wide care improvement and not simply punitive toward individuals.

Punitive ranking systems can have a very detrimental effect on health care, said several experts at the conference. On an individual level, P4P may favor older, more experienced practitioners at the expense of younger ones who may have less experience with a given procedure, and thus may get labeled early on in their careers as “lower quality.” This can make it hard for younger doctors to build practices.

There's also a very real danger, said Dr. Varga, of putting smaller rural practices out of business if Medicare reimbursement is overly tied to rigid performance measures. “You can end up destroying health care delivery for small rural counties. A lot of smaller rural hospitals are working on very small margins. If you take away 5% of their Medicare revenue, they close their doors. They can't take that kind of hit.”

At its best, P4P is a set of tools for improving health care outcomes, reducing iatrogenic illness and adverse events, and improving the overall return on every health care dollar spent. Advocates believe that with the right measures, P4P can achieve these goals.

“I think doctors are motivated to improve if they see objective data that they are not performing as well as their peers. It is not necessarily a financial incentive, but a patient care incentive that will motivate them,” said Dr. Jack Lewin, CEO of the American College of Cardiology. ACC has developed a vigorous program of accountability guidelines aimed at improving the quality of cardiovascular care.

“Ultimately, we want to show individual cardiologists how they are doing in relation to their peers on real world indicators, and we want to give them tools for improvement.” Given that cardiovascular disease consumes over 43% of total health care dollars, a little improvement will go a long way, said Dr. Lewin.

ACC is currently studying “door to balloon” time at major centers, in an effort to reduce the interval from when a patient arrives at a hospital until he or she is in the angioplasty suite. “How fast do the best hospitals get you from the e-room door to the balloon angioplasty? You want this to happen within 90 minutes.”

The National Cardiovascular Data Registries, which ACC supports, represent a major national project aimed at tracking hospital performance on a wide range of procedures including immediate response to acute MI, balloon angioplasty, and implantation of defibrillators. Data are being gathered in roughly 2,300 centers around the country.

“We can tell the medical staff how they are doing compared to their peers,” Dr. Lewin said at the conference, which was sponsored by the Wall Street Journal and CNBC. “We still need the patient outcomes side, but the program is underway, and some states mandate that hospitals participate if they want the states' Medicare and Medicaid data.”

Dr. Peter Angood, codirector of the Joint Commission International's Center for Patient Safety, likened current quality improvement efforts, flawed though they may be, to the airline industry's efforts to improve safety performance.

“It took the aviation industry 40-45 years to improve performance quality and really get continuous quality improvement in place. In health care, we're just passing the stage where we acknowledge there's a problem. How do we compress that 40-year curve down to just one generation?” Dr. Angood asked.

WASHINGTON — If you're of the mind that the pay-for-performance plans instituted by federal as well as private payers are questionable at best and potentially dangerous at worst, don't worry: you're not alone. Many of the leaders of the pay-for-performance movement share those concerns.

Speaking at the fourth World Health Care Congress, advocates of pay-for-performance (P4P) acknowledged that if not designed carefully, these plans can create perverse incentives, warp physician behavior, and ultimately fail in their primary objective of improving health care quality.

P4P leaders admit that in many cases, they're not sure they're tracking the right measures. Even if they do get it right, there is little evidence that the measures are truly meaningful to ordinary people needing to make medical decisions.

This doesn't mean P4P is going away any time soon. In fact, P4P plans will only become more widespread in the coming years, spurred on by Medicare's embrace of the concept. But P4P advocates are rapidly finding out they need to assess the impact of their systems as closely as they monitor physician and hospital performance.

“Everything we do must be monitored for unintended consequences. P4P plans are no different. The movement is in its infancy,” said Dr. Tom Valuck, director of value-based purchasing for the Centers for Medicare and Medicaid Services. He cited a recent Institute of Medicine report concluding that while P4P has potential to improve health care systems, experience is still very limited, close monitoring is essential, and plan developers need to build in provisions for rapid redesign and correction.

“P4P may lead to focus on wrong priorities. For example, we can end up focusing on individual accountability instead of system performance. This raises a lot of questions about rewards and incentives.” Wrongly focused P4P could exacerbate health care disparities, leading to cherry-picking and cream-skimming, and detracting clinical attention from other priorities, he added. “We may end up teaching to the test, while ignoring the bigger picture.”

Dr. Brent James is executive director of the Institute for Healthcare Delivery Research at Intermountain Healthcare, a health system with one of the most proactive quality improvement and performance measurement systems in the nation. An early advocate of P4P, Dr. James said he has learned some important lessons over several attempts at establishing P4P programs.

Where most P4P plans go awry is by being overly focused on arbitrarily-chosen individual physician “accountability” measures and not being focused enough on overall systems process measures that tie back to meaningful clinical outcomes, said Dr. James.

“You have to show end-of-day improvement in care. If everyone is doing 'perfect score' medicine, but there's no improvement in outcomes, it means either people are gaming the system or the measures are irrelevant. If you build for system improvement, you'll get accountability data along the way. Build from the bottom up, so as not to damage care.”

Dr. James defines systems transparency as meaning “you have sufficient information to make a whole series of decisions, and this holds for patients and practitioners alike. It is not as if any one single piece of information tells the whole story or allows one to make a definitive decision. Transparency is a much broader, a much more profound concept than accountability.”

Dr. James said that he is wary of plans that attach heavy financial rewards or penalties to individual physician measures. First, the measures may not be clinically important ones, and may end up rewarding “performance” on tasks that do not really lead to better patient care. Secondly, financial incentives can skew care delivery. “As you attach greater rewards or punishments to achieving a number, you get increasing propensity for suboptimization; you make one area look good at the expense of the others.”

Finally, financial incentives create the wrong sort of motivations. “One of the worst things you can do to physicians is tell them that money is more important than their professional judgment. They will end up believing you,” he said.

An effective P4P program motivates physicians by stressing improved patient care. “Extrinsic awards destroy intrinsic motivation for improvement. Get the professional incentives right and you get system improvement,” said Dr. James.

Tom Sackville, chief executive of International Federation of Health Plans, and former Minister of Health in Britain, strongly agreed. “Doctors are highly trained, independent-minded, intelligent professionals. They know what they have to do. If they perceive distant bureaucrats throwing bits of fish, they'll start behaving like … performing sea lions. Our doctors pride themselves on having a true vocation. We spoil that at our peril.”

“The things that people measure in P4P are dictated by ivory tower thinkers. Their relevance to patients, or even to the administrative process, is very questionable,” said Robert Burney, director of Quality Improvement for the U.S. Department of State.

Dr. James questioned the extent to which P4P data has any relevance to patients at all. “The truth is patients really do not use outcomes statistics to make their health care decisions. They rely on stories, based on relationships. They'll tell you they want data, but when we measure decision making, the data do not drive it. We have several good studies of this topic, where they gave patients carefully prepared statistics. Patients say the stats changed their decisions, but when we look closely, people do not change decisions based on data. Humans are more emotional than statistical.”

If patients tend not to respond to data, physicians will … eventually.

Dr. Varga said doctors tend to go through “a sort of 'Kübler-Ross acceptance process'” when it comes to P4P, going from a denial attitude of, “Your data stinks, its all BS,” through one of, “Your data are meaningful but don't really apply to me,” through, “The reason my data are bad is because everyone's data are bad,” to finally accepting there's a need for improvement. But that's provided a P4P system is truly oriented toward system-wide care improvement and not simply punitive toward individuals.

Punitive ranking systems can have a very detrimental effect on health care, said several experts at the conference. On an individual level, P4P may favor older, more experienced practitioners at the expense of younger ones who may have less experience with a given procedure, and thus may get labeled early on in their careers as “lower quality.” This can make it hard for younger doctors to build practices.

There's also a very real danger, said Dr. Varga, of putting smaller rural practices out of business if Medicare reimbursement is overly tied to rigid performance measures. “You can end up destroying health care delivery for small rural counties. A lot of smaller rural hospitals are working on very small margins. If you take away 5% of their Medicare revenue, they close their doors. They can't take that kind of hit.”

At its best, P4P is a set of tools for improving health care outcomes, reducing iatrogenic illness and adverse events, and improving the overall return on every health care dollar spent. Advocates believe that with the right measures, P4P can achieve these goals.

“I think doctors are motivated to improve if they see objective data that they are not performing as well as their peers. It is not necessarily a financial incentive, but a patient care incentive that will motivate them,” said Dr. Jack Lewin, CEO of the American College of Cardiology. ACC has developed a vigorous program of accountability guidelines aimed at improving the quality of cardiovascular care.

“Ultimately, we want to show individual cardiologists how they are doing in relation to their peers on real world indicators, and we want to give them tools for improvement.” Given that cardiovascular disease consumes over 43% of total health care dollars, a little improvement will go a long way, said Dr. Lewin.

ACC is currently studying “door to balloon” time at major centers, in an effort to reduce the interval from when a patient arrives at a hospital until he or she is in the angioplasty suite. “How fast do the best hospitals get you from the e-room door to the balloon angioplasty? You want this to happen within 90 minutes.”

The National Cardiovascular Data Registries, which ACC supports, represent a major national project aimed at tracking hospital performance on a wide range of procedures including immediate response to acute MI, balloon angioplasty, and implantation of defibrillators. Data are being gathered in roughly 2,300 centers around the country.

“We can tell the medical staff how they are doing compared to their peers,” Dr. Lewin said at the conference, which was sponsored by the Wall Street Journal and CNBC. “We still need the patient outcomes side, but the program is underway, and some states mandate that hospitals participate if they want the states' Medicare and Medicaid data.”

Dr. Peter Angood, codirector of the Joint Commission International's Center for Patient Safety, likened current quality improvement efforts, flawed though they may be, to the airline industry's efforts to improve safety performance.

“It took the aviation industry 40-45 years to improve performance quality and really get continuous quality improvement in place. In health care, we're just passing the stage where we acknowledge there's a problem. How do we compress that 40-year curve down to just one generation?” Dr. Angood asked.

WASHINGTON — If you're of the mind that the pay-for-performance plans instituted by federal as well as private payers are questionable at best and potentially dangerous at worst, don't worry: You're not alone. Many leaders of the pay-for-performance movement share your concerns.

Speaking at the fourth World Health Care Congress, advocates of pay-for-performance (P4P) acknowledged that if not designed carefully, these plans can create perverse incentives, warp physician behavior, and ultimately fail in their primary objective of improving health care quality.

P4P leaders admit that in many cases, they're not sure they're tracking the right measures. Even if they do get it right, there is little evidence that the measures are truly meaningful to ordinary people needing to make medical decisions.

This doesn't mean P4P is going away any time soon. In fact, P4P plans will only become more widespread in the coming years, spurred on by Medicare's embrace of the concept. But P4P advocates are rapidly finding out they need to assess the impact of their systems as closely as they monitor physician and hospital performance.

“Everything we do must be monitored for unintended consequences. P4P plans are no different. The movement is in its infancy,” said Dr. Tom Valuck, director of value-based purchasing for the Centers for Medicare and Medicaid Services. He cited a recent Institute of Medicine report concluding that while P4P has potential to improve health care systems, experience is still very limited, close monitoring is essential, and plan developers need to build in provisions for rapid redesign and correction.

“P4P may lead to focus on wrong priorities. For example, we can end up focusing on individual accountability instead of system performance. This raises a lot of questions about rewards and incentives.” Wrongly focused P4P could exacerbate health care disparities, leading to cherry-picking and cream-skimming, and detracting clinical attention from other priorities, he added. “We may end up teaching to the test, while ignoring the bigger picture.”

Dr. Brent James is executive director of the Institute for Healthcare Delivery Research at Intermountain Healthcare, a health system with one of the most proactive quality improvement and performance measurement systems in the nation. An early advocate of P4P, Dr. James said he has learned some important lessons over several attempts at establishing P4P programs.

Where most P4P plans go awry is by being overly focused on arbitrarily chosen physician “accountability” measures and not focused enough on overall systems process measures that tie back to meaningful clinical outcomes, Dr. James said.

“You have to show end-of-day improvement in care. If everyone is doing 'perfect score' medicine but there's no improvement in outcomes, it means either people are gaming the system or the measures are irrelevant. If you build for system improvement, you'll get accountability data along the way. Build from the bottom up, so as not to damage care.”

Dr. James defines systems transparency as meaning that “you have sufficient information to make a whole series of decisions, and this holds for patients and practitioners alike. It is not as if any one single piece of information tells the whole story or allows one to make a definitive decision. Transparency is a much broader, a much more profound concept than accountability.”

Dr. James said that he is wary of plans that attach heavy financial rewards or penalties to individual physician measures. First, the measures may not be clinically important ones and may end up rewarding “performance” on tasks that do not really lead to better patient care. Second, financial incentives can skew care delivery. “As you attach greater rewards or punishments to achieving a number, you get increasing propensity for suboptimization; you make one area look good at the expense of the others.”

Finally, financial incentives create the wrong sort of motivations. “One of the worst things you can do to physicians is tell them that money is more important than their professional judgment. They will end up believing you,” he said.

An effective P4P program motivates physicians by stressing improved patient care. “Extrinsic awards destroy intrinsic motivation for improvement. Get the professional incentives right and you get system improvement,” Dr. James said.

Tom Sackville, chief executive of International Federation of Health Plans, and former Minister of Health in Britain, strongly agreed. “Doctors are highly trained, independent-minded, intelligent professionals. They know what they have to do. If they perceive distant bureaucrats throwing bits of fish, they'll start behaving like … performing sea lions. Our doctors pride themselves on having a true vocation. We spoil that at our peril.”

“The things that people measure in P4P are dictated by ivory tower thinkers. Their relevance to patients, or even to the administrative process, is very questionable,” said Robert Burney, director of quality improvement for the U.S. Department of State.

Dr. James questioned the extent to which P4P data has any relevance to patients at all. “The truth is patients really do not use outcomes statistics to make their health care decisions. They rely on stories, based on relationships. They'll tell you they want data, but when we measure decision making, the data do not drive it. We have several good studies of this topic, where they gave patients carefully prepared statistics. Patients say the stats changed their decisions, but when we look closely, people do not change decisions based on data. Humans are more emotional than statistical.”

If patients tend not to respond to data, physicians will … eventually.

Dr. Varga said doctors tend to go through “a sort of 'Kübler-Ross acceptance process' when it comes to P4P, going from a denial attitude of, 'Your data stinks, its all BS,' through one of, 'Your data are meaningful but don't really apply to me,' through, 'The reasons my data are bad is because everyone's data are bad,' to finally accepting there's a need for improvement.” But that's provided a P4P system is truly oriented toward system-wide care improvement and not simply punitive toward individuals.

Punitive ranking systems can have a very detrimental effect on health care, several experts said at the conference. On an individual level, P4P may favor older, more experienced practitioners at the expense of younger ones who may have less experience with a given procedure, and thus may get labeled early on in their careers as “lower quality.” This can make it hard for younger doctors to build practices.

There's also a very real danger, Dr. Varga said, of putting smaller rural practices out of business if Medicare reimbursement is overly tied to rigid performance measures. “You can end up destroying health care delivery for small rural counties. A lot of smaller rural hospitals are working on very small margins. If you take away 5% of their Medicare revenue, they close their doors. They can't take that kind of hit.”

At best, P4P is a tool set for improving health care outcomes, reducing iatrogenic illness and adverse events, and improving the overall return on each health care dollar spent. Advocates believe that with the right measures, P4P can achieve these goals.

“I think doctors are motivated to improve if they see objective data that they are not performing as well as their peers. It is not necessarily a financial incentive, but a patient care incentive that will motivate them,” said Dr. Jack Lewin, CEO of the American College of Cardiology. ACC has developed a vigorous program of accountability guidelines aimed at improving the quality of cardiovascular care.

“Ultimately, we want to show individual cardiologists how they are doing in relation to their peers on real world indicators, and we want to give them tools for improvement.” Given that cardiovascular disease consumes more than 43% of total health care dollars, a little improvement will go a long way, Dr. Lewin said.

ACC is currently studying “door to balloon” time at major centers, in an effort to reduce the interval from when a patient arrives at a hospital until he or she is in the angioplasty suite. “How fast do the best hospitals get you from the e-room door to the balloon angioplasty? You want this to happen within 90 minutes.”

The National Cardiovascular Data Registries, which ACC supports, represent a major national project aimed at tracking hospital performance on a wide range of procedures including acute MI, balloon angioplasty, and defibrillator implantation. Data are being gathered in roughly 2,300 centers around the country.

“We can tell the medical staff how they are doing compared to their peers,” Dr. Lewin said at the conference sponsored by the Wall Street Journal and CNBC. “We still need the patient outcomes side, but the program is underway, and some states mandate that hospitals participate if they want the states' Medicare and Medicaid data.”

Dr. Peter Angood, codirector of the Joint Commission International's Center for Patient Safety, likened current quality improvement efforts, flawed though they may be, to the airline industry's efforts to improve safety performance.

“It took the aviation industry 40–45 years to improve performance quality and really get continuous quality improvement in place. In health care, we're just passing the stage where we acknowledge there's a problem. How to compress that 40-year curve down to just one generation?”

WASHINGTON — If you're of the mind that the pay-for-performance plans instituted by federal as well as private payers are questionable at best and potentially dangerous at worst, don't worry: You're not alone. Many leaders of the pay-for-performance movement share your concerns.

Speaking at the fourth World Health Care Congress, advocates of pay-for-performance (P4P) acknowledged that if not designed carefully, these plans can create perverse incentives, warp physician behavior, and ultimately fail in their primary objective of improving health care quality.

P4P leaders admit that in many cases, they're not sure they're tracking the right measures. Even if they do get it right, there is little evidence that the measures are truly meaningful to ordinary people needing to make medical decisions.

This doesn't mean P4P is going away any time soon. In fact, P4P plans will only become more widespread in the coming years, spurred on by Medicare's embrace of the concept. But P4P advocates are rapidly finding out they need to assess the impact of their systems as closely as they monitor physician and hospital performance.

“Everything we do must be monitored for unintended consequences. P4P plans are no different. The movement is in its infancy,” said Dr. Tom Valuck, director of value-based purchasing for the Centers for Medicare and Medicaid Services. He cited a recent Institute of Medicine report concluding that while P4P has potential to improve health care systems, experience is still very limited, close monitoring is essential, and plan developers need to build in provisions for rapid redesign and correction.

“P4P may lead to focus on wrong priorities. For example, we can end up focusing on individual accountability instead of system performance. This raises a lot of questions about rewards and incentives.” Wrongly focused P4P could exacerbate health care disparities, leading to cherry-picking and cream-skimming, and detracting clinical attention from other priorities, he added. “We may end up teaching to the test, while ignoring the bigger picture.”

Dr. Brent James is executive director of the Institute for Healthcare Delivery Research at Intermountain Healthcare, a health system with one of the most proactive quality improvement and performance measurement systems in the nation. An early advocate of P4P, Dr. James said he has learned some important lessons over several attempts at establishing P4P programs.

Where most P4P plans go awry is by being overly focused on arbitrarily chosen physician “accountability” measures and not focused enough on overall systems process measures that tie back to meaningful clinical outcomes, Dr. James said.

“You have to show end-of-day improvement in care. If everyone is doing 'perfect score' medicine but there's no improvement in outcomes, it means either people are gaming the system or the measures are irrelevant. If you build for system improvement, you'll get accountability data along the way. Build from the bottom up, so as not to damage care.”

Dr. James defines systems transparency as meaning that “you have sufficient information to make a whole series of decisions, and this holds for patients and practitioners alike. It is not as if any one single piece of information tells the whole story or allows one to make a definitive decision. Transparency is a much broader, a much more profound concept than accountability.”

Dr. James said that he is wary of plans that attach heavy financial rewards or penalties to individual physician measures. First, the measures may not be clinically important ones and may end up rewarding “performance” on tasks that do not really lead to better patient care. Second, financial incentives can skew care delivery. “As you attach greater rewards or punishments to achieving a number, you get increasing propensity for suboptimization; you make one area look good at the expense of the others.”

Finally, financial incentives create the wrong sort of motivations. “One of the worst things you can do to physicians is tell them that money is more important than their professional judgment. They will end up believing you,” he said.

An effective P4P program motivates physicians by stressing improved patient care. “Extrinsic awards destroy intrinsic motivation for improvement. Get the professional incentives right and you get system improvement,” Dr. James said.

Tom Sackville, chief executive of International Federation of Health Plans, and former Minister of Health in Britain, strongly agreed. “Doctors are highly trained, independent-minded, intelligent professionals. They know what they have to do. If they perceive distant bureaucrats throwing bits of fish, they'll start behaving like … performing sea lions. Our doctors pride themselves on having a true vocation. We spoil that at our peril.”

“The things that people measure in P4P are dictated by ivory tower thinkers. Their relevance to patients, or even to the administrative process, is very questionable,” said Robert Burney, director of quality improvement for the U.S. Department of State.

Dr. James questioned the extent to which P4P data has any relevance to patients at all. “The truth is patients really do not use outcomes statistics to make their health care decisions. They rely on stories, based on relationships. They'll tell you they want data, but when we measure decision making, the data do not drive it. We have several good studies of this topic, where they gave patients carefully prepared statistics. Patients say the stats changed their decisions, but when we look closely, people do not change decisions based on data. Humans are more emotional than statistical.”

If patients tend not to respond to data, physicians will … eventually.

Dr. Varga said doctors tend to go through “a sort of 'Kübler-Ross acceptance process' when it comes to P4P, going from a denial attitude of, 'Your data stinks, its all BS,' through one of, 'Your data are meaningful but don't really apply to me,' through, 'The reasons my data are bad is because everyone's data are bad,' to finally accepting there's a need for improvement.” But that's provided a P4P system is truly oriented toward system-wide care improvement and not simply punitive toward individuals.

Punitive ranking systems can have a very detrimental effect on health care, several experts said at the conference. On an individual level, P4P may favor older, more experienced practitioners at the expense of younger ones who may have less experience with a given procedure, and thus may get labeled early on in their careers as “lower quality.” This can make it hard for younger doctors to build practices.

There's also a very real danger, Dr. Varga said, of putting smaller rural practices out of business if Medicare reimbursement is overly tied to rigid performance measures. “You can end up destroying health care delivery for small rural counties. A lot of smaller rural hospitals are working on very small margins. If you take away 5% of their Medicare revenue, they close their doors. They can't take that kind of hit.”

At best, P4P is a tool set for improving health care outcomes, reducing iatrogenic illness and adverse events, and improving the overall return on each health care dollar spent. Advocates believe that with the right measures, P4P can achieve these goals.

“I think doctors are motivated to improve if they see objective data that they are not performing as well as their peers. It is not necessarily a financial incentive, but a patient care incentive that will motivate them,” said Dr. Jack Lewin, CEO of the American College of Cardiology. ACC has developed a vigorous program of accountability guidelines aimed at improving the quality of cardiovascular care.

“Ultimately, we want to show individual cardiologists how they are doing in relation to their peers on real world indicators, and we want to give them tools for improvement.” Given that cardiovascular disease consumes more than 43% of total health care dollars, a little improvement will go a long way, Dr. Lewin said.

ACC is currently studying “door to balloon” time at major centers, in an effort to reduce the interval from when a patient arrives at a hospital until he or she is in the angioplasty suite. “How fast do the best hospitals get you from the e-room door to the balloon angioplasty? You want this to happen within 90 minutes.”

The National Cardiovascular Data Registries, which ACC supports, represent a major national project aimed at tracking hospital performance on a wide range of procedures including acute MI, balloon angioplasty, and defibrillator implantation. Data are being gathered in roughly 2,300 centers around the country.

“We can tell the medical staff how they are doing compared to their peers,” Dr. Lewin said at the conference sponsored by the Wall Street Journal and CNBC. “We still need the patient outcomes side, but the program is underway, and some states mandate that hospitals participate if they want the states' Medicare and Medicaid data.”

Dr. Peter Angood, codirector of the Joint Commission International's Center for Patient Safety, likened current quality improvement efforts, flawed though they may be, to the airline industry's efforts to improve safety performance.

“It took the aviation industry 40–45 years to improve performance quality and really get continuous quality improvement in place. In health care, we're just passing the stage where we acknowledge there's a problem. How to compress that 40-year curve down to just one generation?”

WASHINGTON — If you're of the mind that the pay-for-performance plans instituted by federal as well as private payers are questionable at best and potentially dangerous at worst, don't worry: You're not alone. Many leaders of the pay-for-performance movement share your concerns.

Speaking at the fourth World Health Care Congress, advocates of pay-for-performance (P4P) acknowledged that if not designed carefully, these plans can create perverse incentives, warp physician behavior, and ultimately fail in their primary objective of improving health care quality.

P4P leaders admit that in many cases, they're not sure they're tracking the right measures. Even if they do get it right, there is little evidence that the measures are truly meaningful to ordinary people needing to make medical decisions.

This doesn't mean P4P is going away any time soon. In fact, P4P plans will only become more widespread in the coming years, spurred on by Medicare's embrace of the concept. But P4P advocates are rapidly finding out they need to assess the impact of their systems as closely as they monitor physician and hospital performance.

“Everything we do must be monitored for unintended consequences. P4P plans are no different. The movement is in its infancy,” said Dr. Tom Valuck, director of value-based purchasing for the Centers for Medicare and Medicaid Services. He cited a recent Institute of Medicine report concluding that while P4P has potential to improve health care systems, experience is still very limited, close monitoring is essential, and plan developers need to build in provisions for rapid redesign and correction.

“P4P may lead to focus on wrong priorities. For example, we can end up focusing on individual accountability instead of system performance. This raises a lot of questions about rewards and incentives.” Wrongly focused P4P could exacerbate health care disparities, leading to cherry-picking and cream-skimming, and detracting clinical attention from other priorities, he added. “We may end up teaching to the test, while ignoring the bigger picture.”

Dr. Brent James is executive director of the Institute for Healthcare Delivery Research at Intermountain Healthcare, a health system with one of the most proactive quality improvement and performance measurement systems in the nation. An early advocate of P4P, Dr. James said he has learned some important lessons over several attempts at establishing P4P programs.

Where most P4P plans go awry is by being overly focused on arbitrarily chosen physician “accountability” measures and not focused enough on overall systems process measures that tie back to meaningful clinical outcomes, Dr. James said.

“You have to show end-of-day improvement in care. If everyone is doing 'perfect score' medicine but there's no improvement in outcomes, it means either people are gaming the system or the measures are irrelevant. If you build for system improvement, you'll get accountability data along the way. Build from the bottom up, so as not to damage care.”

Dr. James defines systems transparency as meaning that “you have sufficient information to make a whole series of decisions, and this holds for patients and practitioners alike. It is not as if any one single piece of information tells the whole story or allows one to make a definitive decision. Transparency is a much broader, a much more profound concept than accountability.”

Dr. James said that he is wary of plans that attach heavy financial rewards or penalties to individual physician measures. First, the measures may not be clinically important ones and may end up rewarding “performance” on tasks that do not really lead to better patient care. Second, financial incentives can skew care delivery. “As you attach greater rewards or punishments to achieving a number, you get increasing propensity for suboptimization; you make one area look good at the expense of the others.”

Finally, financial incentives create the wrong sort of motivations. “One of the worst things you can do to physicians is tell them that money is more important than their professional judgment. They will end up believing you,” he said.

An effective P4P program motivates physicians by stressing improved patient care. “Extrinsic awards destroy intrinsic motivation for improvement. Get the professional incentives right and you get system improvement,” Dr. James said.

Tom Sackville, chief executive of International Federation of Health Plans, and former Minister of Health in Britain, strongly agreed. “Doctors are highly trained, independent-minded, intelligent professionals. They know what they have to do. If they perceive distant bureaucrats throwing bits of fish, they'll start behaving like … performing sea lions. Our doctors pride themselves on having a true vocation. We spoil that at our peril.”

“The things that people measure in P4P are dictated by ivory tower thinkers. Their relevance to patients, or even to the administrative process, is very questionable,” said Robert Burney, director of quality improvement for the U.S. Department of State.

Dr. James questioned the extent to which P4P data has any relevance to patients at all. “The truth is patients really do not use outcomes statistics to make their health care decisions. They rely on stories, based on relationships. They'll tell you they want data, but when we measure decision making, the data do not drive it. We have several good studies of this topic, where they gave patients carefully prepared statistics. Patients say the stats changed their decisions, but when we look closely, people do not change decisions based on data. Humans are more emotional than statistical.”

If patients tend not to respond to data, physicians will … eventually.

Dr. Varga said doctors tend to go through “a sort of 'Kübler-Ross acceptance process' when it comes to P4P, going from a denial attitude of, 'Your data stinks, its all BS,' through one of, 'Your data are meaningful but don't really apply to me,' through, 'The reasons my data are bad is because everyone's data are bad,' to finally accepting there's a need for improvement.” But that's provided a P4P system is truly oriented toward system-wide care improvement and not simply punitive toward individuals.

Punitive ranking systems can have a very detrimental effect on health care, several experts said at the conference. On an individual level, P4P may favor older, more experienced practitioners at the expense of younger ones who may have less experience with a given procedure, and thus may get labeled early on in their careers as “lower quality.” This can make it hard for younger doctors to build practices.

There's also a very real danger, Dr. Varga said, of putting smaller rural practices out of business if Medicare reimbursement is overly tied to rigid performance measures. “You can end up destroying health care delivery for small rural counties. A lot of smaller rural hospitals are working on very small margins. If you take away 5% of their Medicare revenue, they close their doors. They can't take that kind of hit.”

At best, P4P is a tool set for improving health care outcomes, reducing iatrogenic illness and adverse events, and improving the overall return on each health care dollar spent. Advocates believe that with the right measures, P4P can achieve these goals.

“I think doctors are motivated to improve if they see objective data that they are not performing as well as their peers. It is not necessarily a financial incentive, but a patient care incentive that will motivate them,” said Dr. Jack Lewin, CEO of the American College of Cardiology. ACC has developed a vigorous program of accountability guidelines aimed at improving the quality of cardiovascular care.

“Ultimately, we want to show individual cardiologists how they are doing in relation to their peers on real world indicators, and we want to give them tools for improvement.” Given that cardiovascular disease consumes more than 43% of total health care dollars, a little improvement will go a long way, Dr. Lewin said.

ACC is currently studying “door to balloon” time at major centers, in an effort to reduce the interval from when a patient arrives at a hospital until he or she is in the angioplasty suite. “How fast do the best hospitals get you from the e-room door to the balloon angioplasty? You want this to happen within 90 minutes.”

The National Cardiovascular Data Registries, which ACC supports, represent a major national project aimed at tracking hospital performance on a wide range of procedures including acute MI, balloon angioplasty, and defibrillator implantation. Data are being gathered in roughly 2,300 centers around the country.

“We can tell the medical staff how they are doing compared to their peers,” Dr. Lewin said at the conference sponsored by the Wall Street Journal and CNBC. “We still need the patient outcomes side, but the program is underway, and some states mandate that hospitals participate if they want the states' Medicare and Medicaid data.”

Dr. Peter Angood, codirector of the Joint Commission International's Center for Patient Safety, likened current quality improvement efforts, flawed though they may be, to the airline industry's efforts to improve safety performance.

“It took the aviation industry 40–45 years to improve performance quality and really get continuous quality improvement in place. In health care, we're just passing the stage where we acknowledge there's a problem. How to compress that 40-year curve down to just one generation?”

WASHINGTON – If you're of the mind that the pay-for-performance plans instituted by federal as well as private payors are questionable at best, and potentially dangerous at worst, don't worry: You're not alone. Many leaders of the pay-for-performance movement share your concerns.

Speaking at the fourth World Health Care Congress, advocates of pay-for-performance (P4P) acknowledged that if not designed carefully, these plans could create perverse incentives, warp physician behavior, and ultimately fail in their primary objective of improving health care quality.

P4P leaders admit that in many cases, they're not sure they're tracking the right measures. Furthermore, even if they do get it right, there is little evidence that the measures are truly meaningful to ordinary people needing to make medical decisions.

This doesn't mean P4P is going away any time soon. In fact, P4P plans will only become more widespread in the coming years, spurred on by Medicare's embrace of the concept. But P4P advocates are rapidly finding out they need to assess the impact of their systems as closely as they monitor physician and hospital performance.

“Everything we do must be monitored for unintended consequences. P4P plans are no different. The movement is in its infancy,” said Dr. Tom Valuck, director of value-based purchasing for the Centers for Medicare and Medicaid Services. He cited a recent Institute of Medicine report concluding that while P4P has potential to improve health care systems, experience is still very limited, close monitoring is essential, and plan developers need to build in provisions for rapid redesign and correction.

“P4P may lead to focus on wrong priorities,” said Dr. Valuck. “For example, we can end up focusing on individual accountability instead of system performance. This raises a lot of questions about rewards and incentives.”

Wrongly focused P4P could exacerbate health care disparities, leading to cherry-picking and cream-skimming, and detracting clinical attention from other priorities, he added. “We may end up teaching to the test, while ignoring the bigger picture.”

Dr. Brent James is executive director of the Institute for Healthcare Delivery Research at Intermountain Healthcare, a health system with one of the most proactive quality improvement and performance measurement systems in the nation. An early advocate of P4P, Dr. James said he has learned some important lessons over several attempts at establishing P4P programs.

Where most P4P plans go awry is by being overly focused on arbitrarily chosen individual physician “accountability” measures and not being focused enough on overall systems process measures that tie back to meaningful clinical outcomes, said Dr. James.

“You have to show end-of-day improvement in care. If everyone is doing 'perfect score' medicine, but there's no improvement in outcomes, it means either people are gaming the system or the measures are irrelevant. If you build for system improvement, you'll get accountability data along the way. Build from the bottom up, so as not to damage care.”

Dr. James defines systems transparency as meaning that “you have sufficient information to make a whole series of decisions, and this holds for patients and practitioners alike. It is not as if any one single piece of information tells the whole story or allows one to make a definitive decision. Transparency is a much broader, a much more profound concept than accountability.”

Dr. James said that he is wary of plans that attach heavy financial rewards or penalties to individual physician measures. First, the measures may not be clinically important ones and may end up rewarding “performance” on tasks that do not really lead to better patient care. Second, financial incentives can skew care delivery. “As you attach greater rewards or punishments to achieving a number, you get increasing propensity for suboptimization; you make one area look good at the expense of the others.”

Finally, financial incentives create the wrong sort of motivations. “One of the worst things you can do to physicians is tell them that money is more important than their professional judgment. They will end up believing you,” he said.

An effective P4P program motivates physicians by stressing improved patient care. “Extrinsic awards destroy intrinsic motivation for improvement. Get the professional incentives right, and you get system improvement,” said Dr. James.

Tom Sackville, chief executive of International Federation of Health Plans, and former Minister of Health in Britain, strongly agreed. “Doctors are highly trained, independent-minded, intelligent professionals. They know what they have to do. If they perceive distant bureaucrats throwing bits of fish, they'll start behaving like … performing sea lions. Our doctors pride themselves on having a true vocation. We spoil that at our peril.”

“The things that people measure in P4P are dictated by ivory tower thinkers. Their relevance to patients, or even to the administrative process, is very questionable,” said Robert Burney, director of quality improvement for the U.S. Department of State.

Dr. James questioned the extent to which P4P data have any relevance to patients at all. “The truth is, patients really do not use outcomes statistics to make their health care decisions. They rely on stories, based on relationships. They'll tell you they want data, but when we measure decision-making, the data do not drive it. We have several good studies of this topic, where they gave patients carefully prepared statistics. Patients say the stats changed their decisions, but when we look closely, people do not change decisions based on data. Humans are more emotional than statistical.”

If patients tend not to respond to data, physicians will … eventually.

Dr. Varga said doctors tend to go through “a sort of 'Kübler-Ross acceptance process' when it comes to P4P, going from a denial attitude of, “Your data [stink, they're] all B.S.,” through one of, “Your data are meaningful but don't really apply to me,” through, “The reasons my data are bad is because everyone's data are bad,” to finally accepting there's a need for improvement. However, that conclusion depends on the P4P system being truly oriented toward systemwide care improvement and not simply punitive toward individuals.

Punitive ranking systems can have a very detrimental effect on health care, said several experts at the conference.

On an individual level, P4P may favor older, more experienced practitioners at the expense of younger ones who may have less experience with a given procedure, and thus may get labeled early on in their careers as “lower quality.” This can make it hard for younger doctors to build practices.

There's also a very real danger, said Dr. Varga, of putting smaller rural practices out of business if Medicare reimbursement is overly tied to rigid performance measures. “You can end up destroying health care delivery for small rural counties. A lot of smaller rural hospitals are working on very small margins. If you take away 5% of their Medicare revenue, they close their doors. They can't take that kind of hit.”

At its best, P4P is a set of tools for improving health care outcomes, reducing iatrogenic illness and adverse events, and improving the overall return on every health care dollar spent. Advocates believe that with the right measures, P4P can achieve these goals.

“I think doctors are motivated to improve if they see objective data that they are not performing as well as their peers. It is not necessarily a financial incentive, but a patient care incentive that will motivate them,” said Dr. Jack Lewin, CEO of the American College of Cardiology. The ACC has developed a vigorous program of accountability guidelines aimed at improving the quality of cardiovascular care.

“Ultimately, we want to show individual cardiologists how they are doing in relation to their peers on real-world indicators, and we want to give them tools for improvement.” Given that cardiovascular disease consumes over 43% of total health care dollars, a little improvement will go a long way, said Dr. Lewin.

The ACC is currently studying “door-to-balloon” time at major centers, in an effort to reduce the interval from when a patient arrives at a hospital until he or she is in the angioplasty suite.

“How fast do the best hospitals get you from the e-room door to the balloon angioplasty? You want this to happen within 90 minutes,” he added.

The National Cardiovascular Data Registries, which ACC supports, represent a major national project aimed at tracking hospital performance on a wide range of procedures, including immediate response to acute MI, balloon angioplasty, and implantation of defibrillators. Data are being gathered in roughly 2,300 centers around the country.

“We can tell the medical staff how they are doing compared to their peers,” Dr. Lewin said at the conference sponsored by the Wall Street Journal and CNBC. “We still need the patient outcomes side, but the program is underway, and some states mandate that hospitals participate if they want the states' Medicare and Medicaid data.”

Dr. Peter Angood, codirector of the Joint Commission International's Center for Patient Safety, likened current quality improvement efforts, flawed though they may be, to the airline industry's efforts to improve safety.

“It took the aviation industry 40-45 years to improve performance quality and really get continuous quality improvement in place. In health care, we're just passing the stage where we acknowledge there's a problem. How to compress that 40-year curve down to just one generation?”

WASHINGTON – If you're of the mind that the pay-for-performance plans instituted by federal as well as private payors are questionable at best, and potentially dangerous at worst, don't worry: You're not alone. Many leaders of the pay-for-performance movement share your concerns.

Speaking at the fourth World Health Care Congress, advocates of pay-for-performance (P4P) acknowledged that if not designed carefully, these plans could create perverse incentives, warp physician behavior, and ultimately fail in their primary objective of improving health care quality.

P4P leaders admit that in many cases, they're not sure they're tracking the right measures. Furthermore, even if they do get it right, there is little evidence that the measures are truly meaningful to ordinary people needing to make medical decisions.

This doesn't mean P4P is going away any time soon. In fact, P4P plans will only become more widespread in the coming years, spurred on by Medicare's embrace of the concept. But P4P advocates are rapidly finding out they need to assess the impact of their systems as closely as they monitor physician and hospital performance.

“Everything we do must be monitored for unintended consequences. P4P plans are no different. The movement is in its infancy,” said Dr. Tom Valuck, director of value-based purchasing for the Centers for Medicare and Medicaid Services. He cited a recent Institute of Medicine report concluding that while P4P has potential to improve health care systems, experience is still very limited, close monitoring is essential, and plan developers need to build in provisions for rapid redesign and correction.

“P4P may lead to focus on wrong priorities,” said Dr. Valuck. “For example, we can end up focusing on individual accountability instead of system performance. This raises a lot of questions about rewards and incentives.”

Wrongly focused P4P could exacerbate health care disparities, leading to cherry-picking and cream-skimming, and detracting clinical attention from other priorities, he added. “We may end up teaching to the test, while ignoring the bigger picture.”

Dr. Brent James is executive director of the Institute for Healthcare Delivery Research at Intermountain Healthcare, a health system with one of the most proactive quality improvement and performance measurement systems in the nation. An early advocate of P4P, Dr. James said he has learned some important lessons over several attempts at establishing P4P programs.

Where most P4P plans go awry is by being overly focused on arbitrarily chosen individual physician “accountability” measures and not being focused enough on overall systems process measures that tie back to meaningful clinical outcomes, said Dr. James.

“You have to show end-of-day improvement in care. If everyone is doing 'perfect score' medicine, but there's no improvement in outcomes, it means either people are gaming the system or the measures are irrelevant. If you build for system improvement, you'll get accountability data along the way. Build from the bottom up, so as not to damage care.”

Dr. James defines systems transparency as meaning that “you have sufficient information to make a whole series of decisions, and this holds for patients and practitioners alike. It is not as if any one single piece of information tells the whole story or allows one to make a definitive decision. Transparency is a much broader, a much more profound concept than accountability.”

Dr. James said that he is wary of plans that attach heavy financial rewards or penalties to individual physician measures. First, the measures may not be clinically important ones and may end up rewarding “performance” on tasks that do not really lead to better patient care. Second, financial incentives can skew care delivery. “As you attach greater rewards or punishments to achieving a number, you get increasing propensity for suboptimization; you make one area look good at the expense of the others.”

Finally, financial incentives create the wrong sort of motivations. “One of the worst things you can do to physicians is tell them that money is more important than their professional judgment. They will end up believing you,” he said.

An effective P4P program motivates physicians by stressing improved patient care. “Extrinsic awards destroy intrinsic motivation for improvement. Get the professional incentives right, and you get system improvement,” said Dr. James.

Tom Sackville, chief executive of International Federation of Health Plans, and former Minister of Health in Britain, strongly agreed. “Doctors are highly trained, independent-minded, intelligent professionals. They know what they have to do. If they perceive distant bureaucrats throwing bits of fish, they'll start behaving like … performing sea lions. Our doctors pride themselves on having a true vocation. We spoil that at our peril.”

“The things that people measure in P4P are dictated by ivory tower thinkers. Their relevance to patients, or even to the administrative process, is very questionable,” said Robert Burney, director of quality improvement for the U.S. Department of State.

Dr. James questioned the extent to which P4P data have any relevance to patients at all. “The truth is, patients really do not use outcomes statistics to make their health care decisions. They rely on stories, based on relationships. They'll tell you they want data, but when we measure decision-making, the data do not drive it. We have several good studies of this topic, where they gave patients carefully prepared statistics. Patients say the stats changed their decisions, but when we look closely, people do not change decisions based on data. Humans are more emotional than statistical.”

If patients tend not to respond to data, physicians will … eventually.

Dr. Varga said doctors tend to go through “a sort of 'Kübler-Ross acceptance process' when it comes to P4P, going from a denial attitude of, “Your data [stink, they're] all B.S.,” through one of, “Your data are meaningful but don't really apply to me,” through, “The reasons my data are bad is because everyone's data are bad,” to finally accepting there's a need for improvement. However, that conclusion depends on the P4P system being truly oriented toward systemwide care improvement and not simply punitive toward individuals.

Punitive ranking systems can have a very detrimental effect on health care, said several experts at the conference.

On an individual level, P4P may favor older, more experienced practitioners at the expense of younger ones who may have less experience with a given procedure, and thus may get labeled early on in their careers as “lower quality.” This can make it hard for younger doctors to build practices.

There's also a very real danger, said Dr. Varga, of putting smaller rural practices out of business if Medicare reimbursement is overly tied to rigid performance measures. “You can end up destroying health care delivery for small rural counties. A lot of smaller rural hospitals are working on very small margins. If you take away 5% of their Medicare revenue, they close their doors. They can't take that kind of hit.”

At its best, P4P is a set of tools for improving health care outcomes, reducing iatrogenic illness and adverse events, and improving the overall return on every health care dollar spent. Advocates believe that with the right measures, P4P can achieve these goals.

“I think doctors are motivated to improve if they see objective data that they are not performing as well as their peers. It is not necessarily a financial incentive, but a patient care incentive that will motivate them,” said Dr. Jack Lewin, CEO of the American College of Cardiology. The ACC has developed a vigorous program of accountability guidelines aimed at improving the quality of cardiovascular care.

“Ultimately, we want to show individual cardiologists how they are doing in relation to their peers on real-world indicators, and we want to give them tools for improvement.” Given that cardiovascular disease consumes over 43% of total health care dollars, a little improvement will go a long way, said Dr. Lewin.

The ACC is currently studying “door-to-balloon” time at major centers, in an effort to reduce the interval from when a patient arrives at a hospital until he or she is in the angioplasty suite.

“How fast do the best hospitals get you from the e-room door to the balloon angioplasty? You want this to happen within 90 minutes,” he added.

The National Cardiovascular Data Registries, which ACC supports, represent a major national project aimed at tracking hospital performance on a wide range of procedures, including immediate response to acute MI, balloon angioplasty, and implantation of defibrillators. Data are being gathered in roughly 2,300 centers around the country.

“We can tell the medical staff how they are doing compared to their peers,” Dr. Lewin said at the conference sponsored by the Wall Street Journal and CNBC. “We still need the patient outcomes side, but the program is underway, and some states mandate that hospitals participate if they want the states' Medicare and Medicaid data.”

Dr. Peter Angood, codirector of the Joint Commission International's Center for Patient Safety, likened current quality improvement efforts, flawed though they may be, to the airline industry's efforts to improve safety.

“It took the aviation industry 40-45 years to improve performance quality and really get continuous quality improvement in place. In health care, we're just passing the stage where we acknowledge there's a problem. How to compress that 40-year curve down to just one generation?”

WASHINGTON – If you're of the mind that the pay-for-performance plans instituted by federal as well as private payors are questionable at best, and potentially dangerous at worst, don't worry: You're not alone. Many leaders of the pay-for-performance movement share your concerns.

Speaking at the fourth World Health Care Congress, advocates of pay-for-performance (P4P) acknowledged that if not designed carefully, these plans could create perverse incentives, warp physician behavior, and ultimately fail in their primary objective of improving health care quality.

P4P leaders admit that in many cases, they're not sure they're tracking the right measures. Furthermore, even if they do get it right, there is little evidence that the measures are truly meaningful to ordinary people needing to make medical decisions.

This doesn't mean P4P is going away any time soon. In fact, P4P plans will only become more widespread in the coming years, spurred on by Medicare's embrace of the concept. But P4P advocates are rapidly finding out they need to assess the impact of their systems as closely as they monitor physician and hospital performance.

“Everything we do must be monitored for unintended consequences. P4P plans are no different. The movement is in its infancy,” said Dr. Tom Valuck, director of value-based purchasing for the Centers for Medicare and Medicaid Services. He cited a recent Institute of Medicine report concluding that while P4P has potential to improve health care systems, experience is still very limited, close monitoring is essential, and plan developers need to build in provisions for rapid redesign and correction.

“P4P may lead to focus on wrong priorities,” said Dr. Valuck. “For example, we can end up focusing on individual accountability instead of system performance. This raises a lot of questions about rewards and incentives.”

Wrongly focused P4P could exacerbate health care disparities, leading to cherry-picking and cream-skimming, and detracting clinical attention from other priorities, he added. “We may end up teaching to the test, while ignoring the bigger picture.”

Dr. Brent James is executive director of the Institute for Healthcare Delivery Research at Intermountain Healthcare, a health system with one of the most proactive quality improvement and performance measurement systems in the nation. An early advocate of P4P, Dr. James said he has learned some important lessons over several attempts at establishing P4P programs.

Where most P4P plans go awry is by being overly focused on arbitrarily chosen individual physician “accountability” measures and not being focused enough on overall systems process measures that tie back to meaningful clinical outcomes, said Dr. James.

“You have to show end-of-day improvement in care. If everyone is doing 'perfect score' medicine, but there's no improvement in outcomes, it means either people are gaming the system or the measures are irrelevant. If you build for system improvement, you'll get accountability data along the way. Build from the bottom up, so as not to damage care.”

Dr. James defines systems transparency as meaning that “you have sufficient information to make a whole series of decisions, and this holds for patients and practitioners alike. It is not as if any one single piece of information tells the whole story or allows one to make a definitive decision. Transparency is a much broader, a much more profound concept than accountability.”

Dr. James said that he is wary of plans that attach heavy financial rewards or penalties to individual physician measures. First, the measures may not be clinically important ones and may end up rewarding “performance” on tasks that do not really lead to better patient care. Second, financial incentives can skew care delivery. “As you attach greater rewards or punishments to achieving a number, you get increasing propensity for suboptimization; you make one area look good at the expense of the others.”

Finally, financial incentives create the wrong sort of motivations. “One of the worst things you can do to physicians is tell them that money is more important than their professional judgment. They will end up believing you,” he said.

An effective P4P program motivates physicians by stressing improved patient care. “Extrinsic awards destroy intrinsic motivation for improvement. Get the professional incentives right, and you get system improvement,” said Dr. James.

Tom Sackville, chief executive of International Federation of Health Plans, and former Minister of Health in Britain, strongly agreed. “Doctors are highly trained, independent-minded, intelligent professionals. They know what they have to do. If they perceive distant bureaucrats throwing bits of fish, they'll start behaving like … performing sea lions. Our doctors pride themselves on having a true vocation. We spoil that at our peril.”

“The things that people measure in P4P are dictated by ivory tower thinkers. Their relevance to patients, or even to the administrative process, is very questionable,” said Robert Burney, director of quality improvement for the U.S. Department of State.

Dr. James questioned the extent to which P4P data have any relevance to patients at all. “The truth is, patients really do not use outcomes statistics to make their health care decisions. They rely on stories, based on relationships. They'll tell you they want data, but when we measure decision-making, the data do not drive it. We have several good studies of this topic, where they gave patients carefully prepared statistics. Patients say the stats changed their decisions, but when we look closely, people do not change decisions based on data. Humans are more emotional than statistical.”

If patients tend not to respond to data, physicians will … eventually.

Dr. Varga said doctors tend to go through “a sort of 'Kübler-Ross acceptance process' when it comes to P4P, going from a denial attitude of, “Your data [stink, they're] all B.S.,” through one of, “Your data are meaningful but don't really apply to me,” through, “The reasons my data are bad is because everyone's data are bad,” to finally accepting there's a need for improvement. However, that conclusion depends on the P4P system being truly oriented toward systemwide care improvement and not simply punitive toward individuals.

Punitive ranking systems can have a very detrimental effect on health care, said several experts at the conference.

On an individual level, P4P may favor older, more experienced practitioners at the expense of younger ones who may have less experience with a given procedure, and thus may get labeled early on in their careers as “lower quality.” This can make it hard for younger doctors to build practices.

There's also a very real danger, said Dr. Varga, of putting smaller rural practices out of business if Medicare reimbursement is overly tied to rigid performance measures. “You can end up destroying health care delivery for small rural counties. A lot of smaller rural hospitals are working on very small margins. If you take away 5% of their Medicare revenue, they close their doors. They can't take that kind of hit.”

At its best, P4P is a set of tools for improving health care outcomes, reducing iatrogenic illness and adverse events, and improving the overall return on every health care dollar spent. Advocates believe that with the right measures, P4P can achieve these goals.

“I think doctors are motivated to improve if they see objective data that they are not performing as well as their peers. It is not necessarily a financial incentive, but a patient care incentive that will motivate them,” said Dr. Jack Lewin, CEO of the American College of Cardiology. The ACC has developed a vigorous program of accountability guidelines aimed at improving the quality of cardiovascular care.

“Ultimately, we want to show individual cardiologists how they are doing in relation to their peers on real-world indicators, and we want to give them tools for improvement.” Given that cardiovascular disease consumes over 43% of total health care dollars, a little improvement will go a long way, said Dr. Lewin.

The ACC is currently studying “door-to-balloon” time at major centers, in an effort to reduce the interval from when a patient arrives at a hospital until he or she is in the angioplasty suite.

“How fast do the best hospitals get you from the e-room door to the balloon angioplasty? You want this to happen within 90 minutes,” he added.

The National Cardiovascular Data Registries, which ACC supports, represent a major national project aimed at tracking hospital performance on a wide range of procedures, including immediate response to acute MI, balloon angioplasty, and implantation of defibrillators. Data are being gathered in roughly 2,300 centers around the country.

“We can tell the medical staff how they are doing compared to their peers,” Dr. Lewin said at the conference sponsored by the Wall Street Journal and CNBC. “We still need the patient outcomes side, but the program is underway, and some states mandate that hospitals participate if they want the states' Medicare and Medicaid data.”

Dr. Peter Angood, codirector of the Joint Commission International's Center for Patient Safety, likened current quality improvement efforts, flawed though they may be, to the airline industry's efforts to improve safety.

“It took the aviation industry 40-45 years to improve performance quality and really get continuous quality improvement in place. In health care, we're just passing the stage where we acknowledge there's a problem. How to compress that 40-year curve down to just one generation?”

WASHINGTON – The emergence of medical centers in Asia, Latin America, and Eastern Europe that provide state-of-the-art procedures with a human touch and a gentle price tag has many U.S. citizens flying abroad to seek care they might have gotten at their local hospitals.

Medical travel–don't call it medical tourism anymore–has increased rapidly in recent years. In principle, there's nothing really new about it. For years, wealthy individuals from all over the world have flown to the United States or Western Europe for advanced procedures not available at home.

What is new is the ease of medical travel, the numbers of people getting treated away from home, and the direction: away from the United States and toward Asia, Eastern Europe, and Latin America.

Last year, roughly 150,000 Americans headed overseas for surgical procedures, estimated Josef Woodward, author of “Patients Without Borders: Everybody's Guide to Affordable, World-Class Medical Tourism” (Chapel Hill, N.C.: Healthy Travel Media, 2007) the first, but surely not the last, popular book on the subject. His estimate is conservative; some observers put the number at closer to half a million.

Approximately 60,000 Americans have sought care at Bumrungrad International in Bangkok, widely recognized as one of Asia's leading hospitals, according to Curtis Schroeder, group CEO of Bumrungrad.

“Why travel to a hospital you can't even pronounce, in a country you've never visited, with doctors who have strange names you can't spell? There are several reasons: geopolitical factors; economic crises; lack of access to care, which is especially true for uninsured Americans or people from Western Europe who do not want to wait for services provided through their national health care systems; perceived lack of quality of care in their home countries; and family microeconomics,” said Mr. Schroeder, who previously was with Tenet Healthcare Systems, opening Tenet hospitals in several different countries.

Health care abroad is an appealing option for moderate-income Americans who are not insured. But even those with insurance are feeling the pinch and looking overseas. Mr. Schroeder cited a Time magazine survey indicating that 61% of uninsured Americans polled would travel 10,000 miles if they knew they could save $5,000 on a major medical procedure. Among those with insurance, the number was 40%.

“These are the first wave of medical tourists,” he said.

U.S. Standards … or Better

According to Ori Karev, head of UnitedHealthGroup's Ovations program to improve health in people over the age of 50 years, there are 110 hospitals around the world accredited by the Joint Commission International that provide health care that is as good if not better quality than the care at top U.S. hospitals. JCI uses the same criteria as the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), and serves the same general purpose.

The International Organisation for Standardization, a 157-nation network of accrediting institutions based in Geneva, also accredits hospitals and clinics abroad, but focuses mainly on facilities management and administration, not clinical measures.

“While ISO accreditation is good to see, it is of limited value in terms of treatment,” according to Mr. Woodward's book.

JCI-accredited hospitals, many of which are run as joint government-private sector partnerships, are typically founded on the relatively solid economic bedrock of national single-payer health systems. They provide services at far lower cost than U.S. hospitals, in part because the surrounding social and cultural milieu is relatively free from many of the cost drivers in the U.S. system: insurance bureaucracy, tort law, high malpractice settlements, entitlement mentality, and deficit-spending lifestyles.

Once largely confined to elective cosmetic procedures or experimental treatments, medical travel now encompasses everything one would expect at an American or European tertiary-care center, including cardiovascular surgery, organ transplants, hip and knee replacements, and advanced cancer therapies. American- or European-trained clinicians at JCI-accredited hospitals are performing such procedures with outcomes equivalent to any U.S. center, adverse event rates comparable or even substantially lower than at U.S. hospitals, and at markedly reduced costs.

Mr. Woodward estimates Americans traveling for health care can expect to save between 15% and 85% on the cost of equivalent care in the United States. Savings vary widely with the type of procedure, the country visited, and any add-ons such as vacation time. But for most major procedures, the savings are massive. (See box.)

Brazil, Costa Rica, and South Africa currently are hot destinations for cosmetic procedures; Costa Rica, Mexico, and Hungary are magnets for good, affordable dentistry, and India, Thailand, Malaysia, and Singapore are the best choices for major surgeries, including heart surgeries, organ transplants, and orthopedics, according to Mr. Woodward's book.

Friendly Physicians and Fine Food

Cost savings are a primary driver, but it is more than simple economics that attract Americans abroad. The leading international clinics can provide levels of service and comfort almost unheard of in U.S. hospitals.

Doctors in Asia or Latin America spend up to an hour per consultation, and routinely offer their personal cell phone numbers to patients and their families. Concierge services, four-star meal plans, and hotel-style accommodations are the rule, and travel packages often include limousine transport to and from the airport and clinic. The generally slower pace and the traditions of hospitality found overseas also may appeal to Americans shell-shocked by the frazzling pace and impersonal nature of U.S. health care.

Before 1997, the U.S. and Europe were the major recipients of international medical travelers, while Singapore was the major hub for Asia, explained Bumrungrad's Mr. Schroeder. In 1997, the economic crises in many Asian countries made price of care much more of an issue, so more Asians began to travel beyond their home borders for care.

After the terrorist attacks of Sept. 11, 2001, an increasing number of patients from the Middle East began traveling to Asia for care. “They used to go to America or Europe, but visas became problematic, so they started going to Thailand, Singapore, and India,” said Mr. Schroeder. He estimated Bumrungrad served 92,000 people from Middle Eastern countries in the last year, representing about 20% of total international business for the hospital.

In response to the influx of investment capital and international patient volume, hospitals in Thailand, India, and Singapore quickly ramped up their services. They built new facilities, installed state-of-the-art technology, sent physicians abroad for training in advanced therapeutics, and recruited clinicians from abroad.

The Bugbear of Aftercare

Follow-up and recourse if there are complications are a major concern to all involved with medical travel, and it is the aspect of this trend that makes American doctors most nervous.

“It's a very legitimate concern,” agreed Mr. Schroeder. “A lot of the referrals to our hospital do not come from doctors because the patients do not have doctors. They're either outside their home health care systems (i.e., they are uninsured) or they are abandoning their home health care systems. Whenever we can, we do coordinate electronically with our patients' home doctors. If there are complications, we fly patients back, at our own expense, to take care of the problem. We do hold ourselves accountable for complications.”

Medical Outsourcing

According to Mr. Schroeder, “health care costs are capsizing American businesses. They're starting to look at international health care as a form of outsourcing. The idea, while not yet widespread, is gaining traction.”

He noted that Bumrungrad recently signed a landmark deal with Blue Cross of South Carolina for a program called Companion Global Healthcare, which would provide an alternative for people wishing to seek overseas health care.

“It is essentially a pilot project. There's no commercial insurance product attached to it yet. We're exploring processes. It's a learning situation. We're trying to feel it out and see if it can work,” said Mr. Schroeder. The program provides subscribers with access to a specialized travel agency in Virginia that makes all arrangements for medical travel to Bumrungrad, and coordinates aftercare through a network of South Carolina physicians.

But it is only a matter of time before U.S. insurers start actively driving patients overseas, predicted Jeffrey Lefko, a Chicago-based health care consultant who is working with Parkway Group Healthcare, a Singapore-based hospital system, to develop its U.S. referral base.

“It's not happening yet, but it is going to happen, and soon,” Mr. Lefko said in an interview. “A number of U.S. companies have started to work with self-insured plans to make procedures in Singapore a viable option. You're going to see much more of the insurance industry get interested in this.”

Further growth of medical travel, especially if pushed from the home front by U.S. insurers, could have major impact on American health care systems, but Dr. Jason Chin Huat Yap, medical director of the Singapore Tourism Board, said that he believes a lot of the unease surrounding these trends is unwarranted.

“Singapore's share of the global health care economy is about $12.6 billion. The U.S. share is about $2,000 billion. Even if you quadrupled our capacity and you threw in India, too, we're not even able to come close to providing health care for all Americans. It's still a very small fraction. There are massive supply-side constraints. If 1% all U.S. patients came over to Singapore, it would outstrip our capacity. It's really only the first-movers who are going to benefit from this,” he said at the World Health Care Congress.

He added that a little bit of healthy competition from abroad, “could have a potentially positive structural impact on how the U.S. delivers health care services.”

Mr. Lefko said that he believes the emergence of world-class health care systems across the Pacific will likely give U.S. hospitals and clinics a much-needed kick in the bedpan.

“Already 500,000 Americans each year are leaving the U.S. for health care reasons, and this is going to grow. U.S. hospitals and doctors will complain, but the reality is, U.S. hospitals have had plenty of time to straighten out their acts. They've had plenty of opportunities to create better, more economical health care services. Medical tourism's going to level the playing field. I've been in the hospital business for 35 years, and I've seen all sorts of facilities and operations. I wouldn't hesitate to go to any of the hospitals in Singapore,” Mr. Lefko said.

Singapore: a Medical Travel Hot Spot

When it comes to medical travel, Singapore presents a classic case of supply and demand, one official told the World Health Care Congress.

Singapore's tertiary-care hospitals have excess capacity that they're trying to fill. “We have a very small population, and on our own we are not able to maintain the state-of-the-art services. So our approach is to fill the service volume with international patients. That way we can acquire the technology, keep the subspecialists, and provide the highest quality services. We're led by the Ministry of Health in this. It is not just an economic enterprise, it is about providing quality health care for everyone,” said Dr. Jason C. H. Yap, medical director of the Singapore Tourism Board.

Singapore's hospitals are considered the best in Asia, and the sixth best in the world. “We have one-third of all the JCI-accredited facilities, and JCI standards are equivalent or even more stringent than JCAHO's,” said Dr. Yap. “We have lower ICU/CCU infection rates than many centers in the U.S. cities. Health care in Singapore is on par with most U.S. hospitals or better.”

Kamaljeet Singh Gill, general manager of the National Health Care Group, representing several tertiary-care centers in Singapore, explained that his country has a national single-payer health care system, with tiered pricing based on need. “If you have money you pay, if you do not have money you don't pay.” All hospitals in the country are government owned, and they're equivalent to the Mayo Clinic, “but much less expensive.”

Each hospital in Singapore serves about 1 million people annually, 1% of whom are international patients. He said Americans are still in the minority, representing only about 20% of all international business. But the number is growing. “Even without a major marketing effort, we're seeing an increase in U.S. and U.K. patients.”

He stressed that his group is not competing with India or Thailand, and is not promoting “medical tourism,” but rather comprehensive, affordable, state-of-the-art medical services. In addition to treatment and procedures, hospitals in Singapore offer international visitors a wide range of holistic health services, fresh healthy Asian-style food, art and music therapies, and well-designed healing environments of a sort rarely found in U.S. facilities.

Dr. Yap added that this approach represents a strong shift away from the stereotype of medical tourism, which used to mean elective or commodity surgery at facilities with uncertain quality records, questionable marketing methods, and an absence of care continuity.

“Medical travel involves patients going abroad for needed medical care, with minimal leisure components. This is essential health care that, for whatever reason, the individual cannot access at home,” he stressed that medical teams in Singapore endeavor to be part of the normal care continuum and to develop good interconnectivity with the patient's doctors at home. “We prefer that physicians in the patients' home country refer the patients to us. We're not trying to pull patients away from their home doctors.”

Joyce Lim, assistant manager of the International Business Development Unit of Singapore's National Health Care Group, said, “We request referral letters from the patients' doctors at home. Our doctors recommend certain treatments. We let the patients know what is involved. We advise on cost, length of stay, medications, follow-up all beforehand, before [the patient flies to Singapore]. Surgeries are planned very carefully, so there's no waste of time. After treatment, we provide a full medical report that includes all procedures done, all prescriptions, and post-op follow-up recommendations that patients can take back to their physicians. It includes full, 24/7 contact information.”

WASHINGTON – The emergence of medical centers in Asia, Latin America, and Eastern Europe that provide state-of-the-art procedures with a human touch and a gentle price tag has many U.S. citizens flying abroad to seek care they might have gotten at their local hospitals.

Medical travel–don't call it medical tourism anymore–has increased rapidly in recent years. In principle, there's nothing really new about it. For years, wealthy individuals from all over the world have flown to the United States or Western Europe for advanced procedures not available at home.

What is new is the ease of medical travel, the numbers of people getting treated away from home, and the direction: away from the United States and toward Asia, Eastern Europe, and Latin America.

Last year, roughly 150,000 Americans headed overseas for surgical procedures, estimated Josef Woodward, author of “Patients Without Borders: Everybody's Guide to Affordable, World-Class Medical Tourism” (Chapel Hill, N.C.: Healthy Travel Media, 2007) the first, but surely not the last, popular book on the subject. His estimate is conservative; some observers put the number at closer to half a million.

Approximately 60,000 Americans have sought care at Bumrungrad International in Bangkok, widely recognized as one of Asia's leading hospitals, according to Curtis Schroeder, group CEO of Bumrungrad.

“Why travel to a hospital you can't even pronounce, in a country you've never visited, with doctors who have strange names you can't spell? There are several reasons: geopolitical factors; economic crises; lack of access to care, which is especially true for uninsured Americans or people from Western Europe who do not want to wait for services provided through their national health care systems; perceived lack of quality of care in their home countries; and family microeconomics,” said Mr. Schroeder, who previously was with Tenet Healthcare Systems, opening Tenet hospitals in several different countries.

Health care abroad is an appealing option for moderate-income Americans who are not insured. But even those with insurance are feeling the pinch and looking overseas. Mr. Schroeder cited a Time magazine survey indicating that 61% of uninsured Americans polled would travel 10,000 miles if they knew they could save $5,000 on a major medical procedure. Among those with insurance, the number was 40%.

“These are the first wave of medical tourists,” he said.

U.S. Standards … or Better

According to Ori Karev, head of UnitedHealthGroup's Ovations program to improve health in people over the age of 50 years, there are 110 hospitals around the world accredited by the Joint Commission International that provide health care that is as good if not better quality than the care at top U.S. hospitals. JCI uses the same criteria as the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), and serves the same general purpose.

The International Organisation for Standardization, a 157-nation network of accrediting institutions based in Geneva, also accredits hospitals and clinics abroad, but focuses mainly on facilities management and administration, not clinical measures.

“While ISO accreditation is good to see, it is of limited value in terms of treatment,” according to Mr. Woodward's book.

JCI-accredited hospitals, many of which are run as joint government-private sector partnerships, are typically founded on the relatively solid economic bedrock of national single-payer health systems. They provide services at far lower cost than U.S. hospitals, in part because the surrounding social and cultural milieu is relatively free from many of the cost drivers in the U.S. system: insurance bureaucracy, tort law, high malpractice settlements, entitlement mentality, and deficit-spending lifestyles.

Once largely confined to elective cosmetic procedures or experimental treatments, medical travel now encompasses everything one would expect at an American or European tertiary-care center, including cardiovascular surgery, organ transplants, hip and knee replacements, and advanced cancer therapies. American- or European-trained clinicians at JCI-accredited hospitals are performing such procedures with outcomes equivalent to any U.S. center, adverse event rates comparable or even substantially lower than at U.S. hospitals, and at markedly reduced costs.

Mr. Woodward estimates Americans traveling for health care can expect to save between 15% and 85% on the cost of equivalent care in the United States. Savings vary widely with the type of procedure, the country visited, and any add-ons such as vacation time. But for most major procedures, the savings are massive. (See box.)

Brazil, Costa Rica, and South Africa currently are hot destinations for cosmetic procedures; Costa Rica, Mexico, and Hungary are magnets for good, affordable dentistry, and India, Thailand, Malaysia, and Singapore are the best choices for major surgeries, including heart surgeries, organ transplants, and orthopedics, according to Mr. Woodward's book.

Friendly Physicians and Fine Food

Cost savings are a primary driver, but it is more than simple economics that attract Americans abroad. The leading international clinics can provide levels of service and comfort almost unheard of in U.S. hospitals.

Doctors in Asia or Latin America spend up to an hour per consultation, and routinely offer their personal cell phone numbers to patients and their families. Concierge services, four-star meal plans, and hotel-style accommodations are the rule, and travel packages often include limousine transport to and from the airport and clinic. The generally slower pace and the traditions of hospitality found overseas also may appeal to Americans shell-shocked by the frazzling pace and impersonal nature of U.S. health care.

Before 1997, the U.S. and Europe were the major recipients of international medical travelers, while Singapore was the major hub for Asia, explained Bumrungrad's Mr. Schroeder. In 1997, the economic crises in many Asian countries made price of care much more of an issue, so more Asians began to travel beyond their home borders for care.

After the terrorist attacks of Sept. 11, 2001, an increasing number of patients from the Middle East began traveling to Asia for care. “They used to go to America or Europe, but visas became problematic, so they started going to Thailand, Singapore, and India,” said Mr. Schroeder. He estimated Bumrungrad served 92,000 people from Middle Eastern countries in the last year, representing about 20% of total international business for the hospital.

In response to the influx of investment capital and international patient volume, hospitals in Thailand, India, and Singapore quickly ramped up their services. They built new facilities, installed state-of-the-art technology, sent physicians abroad for training in advanced therapeutics, and recruited clinicians from abroad.

The Bugbear of Aftercare

Follow-up and recourse if there are complications are a major concern to all involved with medical travel, and it is the aspect of this trend that makes American doctors most nervous.

“It's a very legitimate concern,” agreed Mr. Schroeder. “A lot of the referrals to our hospital do not come from doctors because the patients do not have doctors. They're either outside their home health care systems (i.e., they are uninsured) or they are abandoning their home health care systems. Whenever we can, we do coordinate electronically with our patients' home doctors. If there are complications, we fly patients back, at our own expense, to take care of the problem. We do hold ourselves accountable for complications.”

Medical Outsourcing

According to Mr. Schroeder, “health care costs are capsizing American businesses. They're starting to look at international health care as a form of outsourcing. The idea, while not yet widespread, is gaining traction.”

He noted that Bumrungrad recently signed a landmark deal with Blue Cross of South Carolina for a program called Companion Global Healthcare, which would provide an alternative for people wishing to seek overseas health care.

“It is essentially a pilot project. There's no commercial insurance product attached to it yet. We're exploring processes. It's a learning situation. We're trying to feel it out and see if it can work,” said Mr. Schroeder. The program provides subscribers with access to a specialized travel agency in Virginia that makes all arrangements for medical travel to Bumrungrad, and coordinates aftercare through a network of South Carolina physicians.

But it is only a matter of time before U.S. insurers start actively driving patients overseas, predicted Jeffrey Lefko, a Chicago-based health care consultant who is working with Parkway Group Healthcare, a Singapore-based hospital system, to develop its U.S. referral base.

“It's not happening yet, but it is going to happen, and soon,” Mr. Lefko said in an interview. “A number of U.S. companies have started to work with self-insured plans to make procedures in Singapore a viable option. You're going to see much more of the insurance industry get interested in this.”

Further growth of medical travel, especially if pushed from the home front by U.S. insurers, could have major impact on American health care systems, but Dr. Jason Chin Huat Yap, medical director of the Singapore Tourism Board, said that he believes a lot of the unease surrounding these trends is unwarranted.

“Singapore's share of the global health care economy is about $12.6 billion. The U.S. share is about $2,000 billion. Even if you quadrupled our capacity and you threw in India, too, we're not even able to come close to providing health care for all Americans. It's still a very small fraction. There are massive supply-side constraints. If 1% all U.S. patients came over to Singapore, it would outstrip our capacity. It's really only the first-movers who are going to benefit from this,” he said at the World Health Care Congress.

He added that a little bit of healthy competition from abroad, “could have a potentially positive structural impact on how the U.S. delivers health care services.”

Mr. Lefko said that he believes the emergence of world-class health care systems across the Pacific will likely give U.S. hospitals and clinics a much-needed kick in the bedpan.

“Already 500,000 Americans each year are leaving the U.S. for health care reasons, and this is going to grow. U.S. hospitals and doctors will complain, but the reality is, U.S. hospitals have had plenty of time to straighten out their acts. They've had plenty of opportunities to create better, more economical health care services. Medical tourism's going to level the playing field. I've been in the hospital business for 35 years, and I've seen all sorts of facilities and operations. I wouldn't hesitate to go to any of the hospitals in Singapore,” Mr. Lefko said.

Singapore: a Medical Travel Hot Spot

When it comes to medical travel, Singapore presents a classic case of supply and demand, one official told the World Health Care Congress.

Singapore's tertiary-care hospitals have excess capacity that they're trying to fill. “We have a very small population, and on our own we are not able to maintain the state-of-the-art services. So our approach is to fill the service volume with international patients. That way we can acquire the technology, keep the subspecialists, and provide the highest quality services. We're led by the Ministry of Health in this. It is not just an economic enterprise, it is about providing quality health care for everyone,” said Dr. Jason C. H. Yap, medical director of the Singapore Tourism Board.

Singapore's hospitals are considered the best in Asia, and the sixth best in the world. “We have one-third of all the JCI-accredited facilities, and JCI standards are equivalent or even more stringent than JCAHO's,” said Dr. Yap. “We have lower ICU/CCU infection rates than many centers in the U.S. cities. Health care in Singapore is on par with most U.S. hospitals or better.”

Kamaljeet Singh Gill, general manager of the National Health Care Group, representing several tertiary-care centers in Singapore, explained that his country has a national single-payer health care system, with tiered pricing based on need. “If you have money you pay, if you do not have money you don't pay.” All hospitals in the country are government owned, and they're equivalent to the Mayo Clinic, “but much less expensive.”

Each hospital in Singapore serves about 1 million people annually, 1% of whom are international patients. He said Americans are still in the minority, representing only about 20% of all international business. But the number is growing. “Even without a major marketing effort, we're seeing an increase in U.S. and U.K. patients.”

He stressed that his group is not competing with India or Thailand, and is not promoting “medical tourism,” but rather comprehensive, affordable, state-of-the-art medical services. In addition to treatment and procedures, hospitals in Singapore offer international visitors a wide range of holistic health services, fresh healthy Asian-style food, art and music therapies, and well-designed healing environments of a sort rarely found in U.S. facilities.

Dr. Yap added that this approach represents a strong shift away from the stereotype of medical tourism, which used to mean elective or commodity surgery at facilities with uncertain quality records, questionable marketing methods, and an absence of care continuity.

“Medical travel involves patients going abroad for needed medical care, with minimal leisure components. This is essential health care that, for whatever reason, the individual cannot access at home,” he stressed that medical teams in Singapore endeavor to be part of the normal care continuum and to develop good interconnectivity with the patient's doctors at home. “We prefer that physicians in the patients' home country refer the patients to us. We're not trying to pull patients away from their home doctors.”

Joyce Lim, assistant manager of the International Business Development Unit of Singapore's National Health Care Group, said, “We request referral letters from the patients' doctors at home. Our doctors recommend certain treatments. We let the patients know what is involved. We advise on cost, length of stay, medications, follow-up all beforehand, before [the patient flies to Singapore]. Surgeries are planned very carefully, so there's no waste of time. After treatment, we provide a full medical report that includes all procedures done, all prescriptions, and post-op follow-up recommendations that patients can take back to their physicians. It includes full, 24/7 contact information.”

WASHINGTON – The emergence of medical centers in Asia, Latin America, and Eastern Europe that provide state-of-the-art procedures with a human touch and a gentle price tag has many U.S. citizens flying abroad to seek care they might have gotten at their local hospitals.

Medical travel–don't call it medical tourism anymore–has increased rapidly in recent years. In principle, there's nothing really new about it. For years, wealthy individuals from all over the world have flown to the United States or Western Europe for advanced procedures not available at home.

What is new is the ease of medical travel, the numbers of people getting treated away from home, and the direction: away from the United States and toward Asia, Eastern Europe, and Latin America.

Last year, roughly 150,000 Americans headed overseas for surgical procedures, estimated Josef Woodward, author of “Patients Without Borders: Everybody's Guide to Affordable, World-Class Medical Tourism” (Chapel Hill, N.C.: Healthy Travel Media, 2007) the first, but surely not the last, popular book on the subject. His estimate is conservative; some observers put the number at closer to half a million.

Approximately 60,000 Americans have sought care at Bumrungrad International in Bangkok, widely recognized as one of Asia's leading hospitals, according to Curtis Schroeder, group CEO of Bumrungrad.

“Why travel to a hospital you can't even pronounce, in a country you've never visited, with doctors who have strange names you can't spell? There are several reasons: geopolitical factors; economic crises; lack of access to care, which is especially true for uninsured Americans or people from Western Europe who do not want to wait for services provided through their national health care systems; perceived lack of quality of care in their home countries; and family microeconomics,” said Mr. Schroeder, who previously was with Tenet Healthcare Systems, opening Tenet hospitals in several different countries.

Health care abroad is an appealing option for moderate-income Americans who are not insured. But even those with insurance are feeling the pinch and looking overseas. Mr. Schroeder cited a Time magazine survey indicating that 61% of uninsured Americans polled would travel 10,000 miles if they knew they could save $5,000 on a major medical procedure. Among those with insurance, the number was 40%.

“These are the first wave of medical tourists,” he said.

U.S. Standards … or Better

According to Ori Karev, head of UnitedHealthGroup's Ovations program to improve health in people over the age of 50 years, there are 110 hospitals around the world accredited by the Joint Commission International that provide health care that is as good if not better quality than the care at top U.S. hospitals. JCI uses the same criteria as the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), and serves the same general purpose.

The International Organisation for Standardization, a 157-nation network of accrediting institutions based in Geneva, also accredits hospitals and clinics abroad, but focuses mainly on facilities management and administration, not clinical measures.

“While ISO accreditation is good to see, it is of limited value in terms of treatment,” according to Mr. Woodward's book.

JCI-accredited hospitals, many of which are run as joint government-private sector partnerships, are typically founded on the relatively solid economic bedrock of national single-payer health systems. They provide services at far lower cost than U.S. hospitals, in part because the surrounding social and cultural milieu is relatively free from many of the cost drivers in the U.S. system: insurance bureaucracy, tort law, high malpractice settlements, entitlement mentality, and deficit-spending lifestyles.

Once largely confined to elective cosmetic procedures or experimental treatments, medical travel now encompasses everything one would expect at an American or European tertiary-care center, including cardiovascular surgery, organ transplants, hip and knee replacements, and advanced cancer therapies. American- or European-trained clinicians at JCI-accredited hospitals are performing such procedures with outcomes equivalent to any U.S. center, adverse event rates comparable or even substantially lower than at U.S. hospitals, and at markedly reduced costs.

Mr. Woodward estimates Americans traveling for health care can expect to save between 15% and 85% on the cost of equivalent care in the United States. Savings vary widely with the type of procedure, the country visited, and any add-ons such as vacation time. But for most major procedures, the savings are massive. (See box.)

Brazil, Costa Rica, and South Africa currently are hot destinations for cosmetic procedures; Costa Rica, Mexico, and Hungary are magnets for good, affordable dentistry, and India, Thailand, Malaysia, and Singapore are the best choices for major surgeries, including heart surgeries, organ transplants, and orthopedics, according to Mr. Woodward's book.

Friendly Physicians and Fine Food

Cost savings are a primary driver, but it is more than simple economics that attract Americans abroad. The leading international clinics can provide levels of service and comfort almost unheard of in U.S. hospitals.

Doctors in Asia or Latin America spend up to an hour per consultation, and routinely offer their personal cell phone numbers to patients and their families. Concierge services, four-star meal plans, and hotel-style accommodations are the rule, and travel packages often include limousine transport to and from the airport and clinic. The generally slower pace and the traditions of hospitality found overseas also may appeal to Americans shell-shocked by the frazzling pace and impersonal nature of U.S. health care.

Before 1997, the U.S. and Europe were the major recipients of international medical travelers, while Singapore was the major hub for Asia, explained Bumrungrad's Mr. Schroeder. In 1997, the economic crises in many Asian countries made price of care much more of an issue, so more Asians began to travel beyond their home borders for care.

After the terrorist attacks of Sept. 11, 2001, an increasing number of patients from the Middle East began traveling to Asia for care. “They used to go to America or Europe, but visas became problematic, so they started going to Thailand, Singapore, and India,” said Mr. Schroeder. He estimated Bumrungrad served 92,000 people from Middle Eastern countries in the last year, representing about 20% of total international business for the hospital.

In response to the influx of investment capital and international patient volume, hospitals in Thailand, India, and Singapore quickly ramped up their services. They built new facilities, installed state-of-the-art technology, sent physicians abroad for training in advanced therapeutics, and recruited clinicians from abroad.

The Bugbear of Aftercare

Follow-up and recourse if there are complications are a major concern to all involved with medical travel, and it is the aspect of this trend that makes American doctors most nervous.

“It's a very legitimate concern,” agreed Mr. Schroeder. “A lot of the referrals to our hospital do not come from doctors because the patients do not have doctors. They're either outside their home health care systems (i.e., they are uninsured) or they are abandoning their home health care systems. Whenever we can, we do coordinate electronically with our patients' home doctors. If there are complications, we fly patients back, at our own expense, to take care of the problem. We do hold ourselves accountable for complications.”

Medical Outsourcing

According to Mr. Schroeder, “health care costs are capsizing American businesses. They're starting to look at international health care as a form of outsourcing. The idea, while not yet widespread, is gaining traction.”

He noted that Bumrungrad recently signed a landmark deal with Blue Cross of South Carolina for a program called Companion Global Healthcare, which would provide an alternative for people wishing to seek overseas health care.

“It is essentially a pilot project. There's no commercial insurance product attached to it yet. We're exploring processes. It's a learning situation. We're trying to feel it out and see if it can work,” said Mr. Schroeder. The program provides subscribers with access to a specialized travel agency in Virginia that makes all arrangements for medical travel to Bumrungrad, and coordinates aftercare through a network of South Carolina physicians.

But it is only a matter of time before U.S. insurers start actively driving patients overseas, predicted Jeffrey Lefko, a Chicago-based health care consultant who is working with Parkway Group Healthcare, a Singapore-based hospital system, to develop its U.S. referral base.

“It's not happening yet, but it is going to happen, and soon,” Mr. Lefko said in an interview. “A number of U.S. companies have started to work with self-insured plans to make procedures in Singapore a viable option. You're going to see much more of the insurance industry get interested in this.”

Further growth of medical travel, especially if pushed from the home front by U.S. insurers, could have major impact on American health care systems, but Dr. Jason Chin Huat Yap, medical director of the Singapore Tourism Board, said that he believes a lot of the unease surrounding these trends is unwarranted.

“Singapore's share of the global health care economy is about $12.6 billion. The U.S. share is about $2,000 billion. Even if you quadrupled our capacity and you threw in India, too, we're not even able to come close to providing health care for all Americans. It's still a very small fraction. There are massive supply-side constraints. If 1% all U.S. patients came over to Singapore, it would outstrip our capacity. It's really only the first-movers who are going to benefit from this,” he said at the World Health Care Congress.

He added that a little bit of healthy competition from abroad, “could have a potentially positive structural impact on how the U.S. delivers health care services.”

Mr. Lefko said that he believes the emergence of world-class health care systems across the Pacific will likely give U.S. hospitals and clinics a much-needed kick in the bedpan.

“Already 500,000 Americans each year are leaving the U.S. for health care reasons, and this is going to grow. U.S. hospitals and doctors will complain, but the reality is, U.S. hospitals have had plenty of time to straighten out their acts. They've had plenty of opportunities to create better, more economical health care services. Medical tourism's going to level the playing field. I've been in the hospital business for 35 years, and I've seen all sorts of facilities and operations. I wouldn't hesitate to go to any of the hospitals in Singapore,” Mr. Lefko said.

Singapore: a Medical Travel Hot Spot

When it comes to medical travel, Singapore presents a classic case of supply and demand, one official told the World Health Care Congress.

Singapore's tertiary-care hospitals have excess capacity that they're trying to fill. “We have a very small population, and on our own we are not able to maintain the state-of-the-art services. So our approach is to fill the service volume with international patients. That way we can acquire the technology, keep the subspecialists, and provide the highest quality services. We're led by the Ministry of Health in this. It is not just an economic enterprise, it is about providing quality health care for everyone,” said Dr. Jason C. H. Yap, medical director of the Singapore Tourism Board.

Singapore's hospitals are considered the best in Asia, and the sixth best in the world. “We have one-third of all the JCI-accredited facilities, and JCI standards are equivalent or even more stringent than JCAHO's,” said Dr. Yap. “We have lower ICU/CCU infection rates than many centers in the U.S. cities. Health care in Singapore is on par with most U.S. hospitals or better.”

Kamaljeet Singh Gill, general manager of the National Health Care Group, representing several tertiary-care centers in Singapore, explained that his country has a national single-payer health care system, with tiered pricing based on need. “If you have money you pay, if you do not have money you don't pay.” All hospitals in the country are government owned, and they're equivalent to the Mayo Clinic, “but much less expensive.”

Each hospital in Singapore serves about 1 million people annually, 1% of whom are international patients. He said Americans are still in the minority, representing only about 20% of all international business. But the number is growing. “Even without a major marketing effort, we're seeing an increase in U.S. and U.K. patients.”

He stressed that his group is not competing with India or Thailand, and is not promoting “medical tourism,” but rather comprehensive, affordable, state-of-the-art medical services. In addition to treatment and procedures, hospitals in Singapore offer international visitors a wide range of holistic health services, fresh healthy Asian-style food, art and music therapies, and well-designed healing environments of a sort rarely found in U.S. facilities.

Dr. Yap added that this approach represents a strong shift away from the stereotype of medical tourism, which used to mean elective or commodity surgery at facilities with uncertain quality records, questionable marketing methods, and an absence of care continuity.

“Medical travel involves patients going abroad for needed medical care, with minimal leisure components. This is essential health care that, for whatever reason, the individual cannot access at home,” he stressed that medical teams in Singapore endeavor to be part of the normal care continuum and to develop good interconnectivity with the patient's doctors at home. “We prefer that physicians in the patients' home country refer the patients to us. We're not trying to pull patients away from their home doctors.”

Joyce Lim, assistant manager of the International Business Development Unit of Singapore's National Health Care Group, said, “We request referral letters from the patients' doctors at home. Our doctors recommend certain treatments. We let the patients know what is involved. We advise on cost, length of stay, medications, follow-up all beforehand, before [the patient flies to Singapore]. Surgeries are planned very carefully, so there's no waste of time. After treatment, we provide a full medical report that includes all procedures done, all prescriptions, and post-op follow-up recommendations that patients can take back to their physicians. It includes full, 24/7 contact information.”

WASHINGTON – The emergence of medical centers in Asia, Latin America, and Eastern Europe that provide state-of-the-art procedures with a human touch and a gentle price tag has many U.S. citizens flying abroad to seek care they might have gotten at their local hospitals.

Medical travel–don't call it medical tourism anymore–has increased rapidly in recent years. In principle, there's nothing really new about it. For years, wealthy individuals from all over the world have flown to the United States or Western Europe for advanced procedures not available at home.

What is new is the ease of medical travel, the numbers of people getting treated away from home, and the direction: away from the United States and toward Asia, Eastern Europe, and Latin America.

Last year, roughly 150,000 Americans headed overseas for surgical procedures, estimated Josef Woodward, author of “Patients Without Borders: Everybody's Guide to Affordable, World-Class Medical Tourism” (Chapel Hill, N.C.: Healthy Travel Media, 2007) the first, but surely not the last, popular book on the subject. His estimate is conservative: some observers put the number at closer to half a million.

Roughly 60,000 Americans have sought care at Bumrungrad International in Bangkok, widely recognized as one of Asia's leading hospitals, according to Curtis Schroeder, group CEO of Bumrungrad.

“Why travel to a hospital you can't even pronounce, in a country you've never visited, with doctors who have strange names you can't spell? There are several reasons: geopolitical factors; economic crises; lack of access to care, which is especially true for uninsured Americans or people from Western Europe who do not want to wait for services provided through their national health care systems; perceived lack of quality of care in their home countries; and family microeconomics,” said Mr. Schroeder, who previously was with Tenet Healthcare Systems, opening Tenet hospitals in several different countries.

Health care abroad is an appealing option for moderate-income Americans who are not insured. But even those with insurance are feeling the pinch and looking overseas. Mr. Schroeder cited a Time magazine survey indicating that 61% of uninsured Americans polled would travel 10,000 miles if they knew they could save $5,000 on a major medical procedure. Among those with insurance, the number was 40%.

“These are the first wave of medical tourists,” he said.

U.S. Standards … Better

According to Ori Karev, head of UnitedHealthGroup's Ovations program to improve health in people over age 50 years, there are 110 hospitals around the world accredited by the Joint Commission International, that provide as good if not better quality health care than what is available at top U.S. hospitals. JCI uses the same criteria as the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), and serves the same general purpose.

JCI-accredited hospitals, many of which are run as joint government-private sector partnerships provide services at far lower cost than U.S. hospitals. And American- or European-trained clinicians at JCI-accredited hospitals are performing cardiovascular surgery, organ transplants, and hip and knee replacements with outcomes equivalent to any U.S. center and adverse event rates comparable with or even substantially lower than at U.S. hospitals.

Mr. Woodward estimates Americans traveling for health care can expect to save between 15% and 85% on the cost of equivalent care in the United States. Savings vary widely with the type of procedure, the country visited, and any add-ons such as vacation time. But for most major procedures the savings are massive. (See box.)

Brazil, Costa Rica, and South Africa currently are hot destinations for cosmetic procedures; Costa Rica, Mexico, and Hungary are magnets for good, affordable dentistry, and India, Thailand, Malaysia, and Singapore are the best choices for major surgeries, including heart surgeries, organ transplants, and orthopedics, according to Mr. Woodward's book.

Friendly Care, Fine Food, Feng Shui

Doctors in Asia or Latin America spend up to an hour per consultation, and routinely offer their personal cell phone numbers to patients and their families. Concierge services, four-star meal plans, and hotel-style accommodations are the rule, and travel packages often include limousine transport to and from the airport and clinic. The generally slower pace and the traditions of hospitality found overseas also may appeal to Americans shell-shocked by the frazzling pace and impersonal nature of U.S. health care.

Before 1997, the U.S. and Europe were the major recipients of international medical travelers, while Singapore was the major hub for Asia, explained Bumrungrad's Mr. Schroeder. In 1997, the economic crises in many Asian countries made price of care much more of an issue, so more Asians began to travel beyond their home borders for care.

After the attacks of Sept. 11, 2001, an increasing number of patients from the Middle East began traveling to Asia for care. “They used to go to America or Europe, but visas became problematic, so they started going to Thailand, Singapore, and India,” Mr. Schroeder said.

Medical Outsourcing

According to Mr. Schroeder, “health care costs are capsizing American businesses. They're starting to look at international health care as a form of outsourcing.”

He noted that Bumrungrad recently signed a landmark deal with Blue Cross of South Carolina for a program called Companion Global Healthcare, which would provide an alternative for people wishing to seek overseas health care.

“It is essentially a pilot project. There's no commercial insurance product attached to it yet,” Mr. Schroeder said. The program provides subscribers with access to a specialized travel agency in Virginia that makes all arrangements for medical travel to Bumrungrad, and coordinates after-care through a network of South Carolina physicians.

But it is only a matter of time before U.S. insurers start actively driving patients overseas, predicted Jeffrey Lefko, a Chicago-based health care consultant who is working with Parkway Group Healthcare, a Singapore-based hospital system, to develop its U.S. referral base.

“A number of U.S. companies have started to work with self-insured plans to make procedures in Singapore a viable option. You're going to see much more of the insurance industry get interested in this,” Mr. Lefko said in an interview.

Further growth of medical travel, especially if pushed from the home front by U.S. insurers, could have a major impact on American health care systems, but Dr. Jason Chin Huat Yap, medical director of the Singapore Tourism Board, said he believes a lot of the unease surrounding these trends is unwarranted.

“Singapore's share of the global health care economy is about $12.6 billion. The U.S. share is about $2,000 billion. Even if you quadrupled our capacity and you threw in India, too, we're not even able to come close to providing health care for all Americans. It's still a very small fraction,” he said at the World Health Care Congress.

He added that a little bit of healthy competition from abroad, “could have a potentially positive structural impact on how the U.S. delivers health care services.”

Mr. Lefko said he believes the emergence of world-class health care systems across the Pacific will likely give U.S. hospitals and clinics a much-needed kick in the bedpan.

“Already 500,000 Americans each year are leaving the U.S. for health care reasons, and this is going to grow. U.S. hospitals and doctors will complain, but the reality is, U.S. hospitals have had plenty of time to straighten out their acts. They've had plenty of opportunities to create better, more economical health care services. Medical tourism's going to level the playing field. I've been in the hospital business for 35 years, and I've seen all sorts of facilities and operations,” Mr. Lefko said. “I wouldn't hesitate to go to any of the hospitals in Singapore.”

A Medical Travel Hot Spot: Singapore

When it comes to medical travel, Singapore presents a classic case of supply and demand, Dr. Yap said at the World Health Care Congress.

Singapore's tertiary-care hospitals have excess capacity that they're trying to fill. “We have a very small population, and on our own we are not able to maintain the state-of-the-art services. So our approach is to fill the service volume with international patients. That way we can acquire the technology, keep the subspecialists, and provide the highest quality services. We're led by the Ministry of Health in this. It is not just an economic enterprise, it is about providing quality health care for everyone,” said Dr. Yap, medical director of the Singapore Tourism Board.

Singapore's hospitals are considered the best in Asia, and the sixth best in the world. “We have one-third of all the JCI accredited facilities, and JCI standards are equivalent or even more stringent than JCAHO's,” Dr. Yap said. “We have lower ICU/CCU infection rates than many centers in the U.S. cities. Health care in Singapore is on par with most U.S. hospitals or better.”

Kamaljeet Singh Gill, general manager of the National Health Care Group, representing several tertiary-care centers in Singapore, explained that his country has a national single-payer health care system, with tiered pricing based on need. “If you have money you pay, if you do not have money you don't pay.” All hospitals in the country are government owned, and they're equivalent to the Mayo Clinic, “but much less expensive.”

Each hospital in Singapore serves about 1 million people annually, 1% of whom are international patients. He said Americans are still in the minority, representing only about 20% of all international business. But the number is growing. “Even without major marketing effort, we're seeing an increase in U.S. and U.K. patients.”

He stressed that his group is not competing with India or Thailand, and is not promoting “medical tourism,” but rather comprehensive affordable state-of-the-art medical services. In addition to treatment and procedures, hospitals in Singapore offer international visitors a wide range of holistic health services, fresh healthy Asian-style food, art and music therapies, and well-designed healing environments of a sort rarely found in U.S. facilities.

Dr. Yap added that this approach represents a strong shift away from the stereotype of medical tourism, which used to mean elective or commodity surgery at facilities with uncertain quality records, questionable marketing methods, and an absence of care continuity.

“Medical travel involves patients going abroad for needed medical care, with minimal leisure components. This is essential health care that, for whatever reason, the individual cannot access at home,” he stressed that medical teams in Singapore endeavor to be part of the normal care continuum and to develop good interconnectivity with the patient's doctors at home. “We prefer that physicians in the patients' home country refer the patient to us. We're not trying to pull patients away from their home doctors.”

WASHINGTON – The emergence of medical centers in Asia, Latin America, and Eastern Europe that provide state-of-the-art procedures with a human touch and a gentle price tag has many U.S. citizens flying abroad to seek care they might have gotten at their local hospitals.

Medical travel–don't call it medical tourism anymore–has increased rapidly in recent years. In principle, there's nothing really new about it. For years, wealthy individuals from all over the world have flown to the United States or Western Europe for advanced procedures not available at home.

What is new is the ease of medical travel, the numbers of people getting treated away from home, and the direction: away from the United States and toward Asia, Eastern Europe, and Latin America.

Last year, roughly 150,000 Americans headed overseas for surgical procedures, estimated Josef Woodward, author of “Patients Without Borders: Everybody's Guide to Affordable, World-Class Medical Tourism” (Chapel Hill, N.C.: Healthy Travel Media, 2007) the first, but surely not the last, popular book on the subject. His estimate is conservative: some observers put the number at closer to half a million.

Roughly 60,000 Americans have sought care at Bumrungrad International in Bangkok, widely recognized as one of Asia's leading hospitals, according to Curtis Schroeder, group CEO of Bumrungrad.

“Why travel to a hospital you can't even pronounce, in a country you've never visited, with doctors who have strange names you can't spell? There are several reasons: geopolitical factors; economic crises; lack of access to care, which is especially true for uninsured Americans or people from Western Europe who do not want to wait for services provided through their national health care systems; perceived lack of quality of care in their home countries; and family microeconomics,” said Mr. Schroeder, who previously was with Tenet Healthcare Systems, opening Tenet hospitals in several different countries.

Health care abroad is an appealing option for moderate-income Americans who are not insured. But even those with insurance are feeling the pinch and looking overseas. Mr. Schroeder cited a Time magazine survey indicating that 61% of uninsured Americans polled would travel 10,000 miles if they knew they could save $5,000 on a major medical procedure. Among those with insurance, the number was 40%.

“These are the first wave of medical tourists,” he said.

U.S. Standards … Better

According to Ori Karev, head of UnitedHealthGroup's Ovations program to improve health in people over age 50 years, there are 110 hospitals around the world accredited by the Joint Commission International, that provide as good if not better quality health care than what is available at top U.S. hospitals. JCI uses the same criteria as the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), and serves the same general purpose.

JCI-accredited hospitals, many of which are run as joint government-private sector partnerships provide services at far lower cost than U.S. hospitals. And American- or European-trained clinicians at JCI-accredited hospitals are performing cardiovascular surgery, organ transplants, and hip and knee replacements with outcomes equivalent to any U.S. center and adverse event rates comparable with or even substantially lower than at U.S. hospitals.

Mr. Woodward estimates Americans traveling for health care can expect to save between 15% and 85% on the cost of equivalent care in the United States. Savings vary widely with the type of procedure, the country visited, and any add-ons such as vacation time. But for most major procedures the savings are massive. (See box.)

Brazil, Costa Rica, and South Africa currently are hot destinations for cosmetic procedures; Costa Rica, Mexico, and Hungary are magnets for good, affordable dentistry, and India, Thailand, Malaysia, and Singapore are the best choices for major surgeries, including heart surgeries, organ transplants, and orthopedics, according to Mr. Woodward's book.

Friendly Care, Fine Food, Feng Shui

Doctors in Asia or Latin America spend up to an hour per consultation, and routinely offer their personal cell phone numbers to patients and their families. Concierge services, four-star meal plans, and hotel-style accommodations are the rule, and travel packages often include limousine transport to and from the airport and clinic. The generally slower pace and the traditions of hospitality found overseas also may appeal to Americans shell-shocked by the frazzling pace and impersonal nature of U.S. health care.

Before 1997, the U.S. and Europe were the major recipients of international medical travelers, while Singapore was the major hub for Asia, explained Bumrungrad's Mr. Schroeder. In 1997, the economic crises in many Asian countries made price of care much more of an issue, so more Asians began to travel beyond their home borders for care.

After the attacks of Sept. 11, 2001, an increasing number of patients from the Middle East began traveling to Asia for care. “They used to go to America or Europe, but visas became problematic, so they started going to Thailand, Singapore, and India,” Mr. Schroeder said.

Medical Outsourcing

According to Mr. Schroeder, “health care costs are capsizing American businesses. They're starting to look at international health care as a form of outsourcing.”

He noted that Bumrungrad recently signed a landmark deal with Blue Cross of South Carolina for a program called Companion Global Healthcare, which would provide an alternative for people wishing to seek overseas health care.

“It is essentially a pilot project. There's no commercial insurance product attached to it yet,” Mr. Schroeder said. The program provides subscribers with access to a specialized travel agency in Virginia that makes all arrangements for medical travel to Bumrungrad, and coordinates after-care through a network of South Carolina physicians.

But it is only a matter of time before U.S. insurers start actively driving patients overseas, predicted Jeffrey Lefko, a Chicago-based health care consultant who is working with Parkway Group Healthcare, a Singapore-based hospital system, to develop its U.S. referral base.

“A number of U.S. companies have started to work with self-insured plans to make procedures in Singapore a viable option. You're going to see much more of the insurance industry get interested in this,” Mr. Lefko said in an interview.

Further growth of medical travel, especially if pushed from the home front by U.S. insurers, could have a major impact on American health care systems, but Dr. Jason Chin Huat Yap, medical director of the Singapore Tourism Board, said he believes a lot of the unease surrounding these trends is unwarranted.

“Singapore's share of the global health care economy is about $12.6 billion. The U.S. share is about $2,000 billion. Even if you quadrupled our capacity and you threw in India, too, we're not even able to come close to providing health care for all Americans. It's still a very small fraction,” he said at the World Health Care Congress.

He added that a little bit of healthy competition from abroad, “could have a potentially positive structural impact on how the U.S. delivers health care services.”

Mr. Lefko said he believes the emergence of world-class health care systems across the Pacific will likely give U.S. hospitals and clinics a much-needed kick in the bedpan.

“Already 500,000 Americans each year are leaving the U.S. for health care reasons, and this is going to grow. U.S. hospitals and doctors will complain, but the reality is, U.S. hospitals have had plenty of time to straighten out their acts. They've had plenty of opportunities to create better, more economical health care services. Medical tourism's going to level the playing field. I've been in the hospital business for 35 years, and I've seen all sorts of facilities and operations,” Mr. Lefko said. “I wouldn't hesitate to go to any of the hospitals in Singapore.”

A Medical Travel Hot Spot: Singapore

When it comes to medical travel, Singapore presents a classic case of supply and demand, Dr. Yap said at the World Health Care Congress.

Singapore's tertiary-care hospitals have excess capacity that they're trying to fill. “We have a very small population, and on our own we are not able to maintain the state-of-the-art services. So our approach is to fill the service volume with international patients. That way we can acquire the technology, keep the subspecialists, and provide the highest quality services. We're led by the Ministry of Health in this. It is not just an economic enterprise, it is about providing quality health care for everyone,” said Dr. Yap, medical director of the Singapore Tourism Board.

Singapore's hospitals are considered the best in Asia, and the sixth best in the world. “We have one-third of all the JCI accredited facilities, and JCI standards are equivalent or even more stringent than JCAHO's,” Dr. Yap said. “We have lower ICU/CCU infection rates than many centers in the U.S. cities. Health care in Singapore is on par with most U.S. hospitals or better.”

Kamaljeet Singh Gill, general manager of the National Health Care Group, representing several tertiary-care centers in Singapore, explained that his country has a national single-payer health care system, with tiered pricing based on need. “If you have money you pay, if you do not have money you don't pay.” All hospitals in the country are government owned, and they're equivalent to the Mayo Clinic, “but much less expensive.”

Each hospital in Singapore serves about 1 million people annually, 1% of whom are international patients. He said Americans are still in the minority, representing only about 20% of all international business. But the number is growing. “Even without major marketing effort, we're seeing an increase in U.S. and U.K. patients.”

He stressed that his group is not competing with India or Thailand, and is not promoting “medical tourism,” but rather comprehensive affordable state-of-the-art medical services. In addition to treatment and procedures, hospitals in Singapore offer international visitors a wide range of holistic health services, fresh healthy Asian-style food, art and music therapies, and well-designed healing environments of a sort rarely found in U.S. facilities.

Dr. Yap added that this approach represents a strong shift away from the stereotype of medical tourism, which used to mean elective or commodity surgery at facilities with uncertain quality records, questionable marketing methods, and an absence of care continuity.

“Medical travel involves patients going abroad for needed medical care, with minimal leisure components. This is essential health care that, for whatever reason, the individual cannot access at home,” he stressed that medical teams in Singapore endeavor to be part of the normal care continuum and to develop good interconnectivity with the patient's doctors at home. “We prefer that physicians in the patients' home country refer the patient to us. We're not trying to pull patients away from their home doctors.”

WASHINGTON – The emergence of medical centers in Asia, Latin America, and Eastern Europe that provide state-of-the-art procedures with a human touch and a gentle price tag has many U.S. citizens flying abroad to seek care they might have gotten at their local hospitals.

Medical travel–don't call it medical tourism anymore–has increased rapidly in recent years. In principle, there's nothing really new about it. For years, wealthy individuals from all over the world have flown to the United States or Western Europe for advanced procedures not available at home.

What is new is the ease of medical travel, the numbers of people getting treated away from home, and the direction: away from the United States and toward Asia, Eastern Europe, and Latin America.

Last year, roughly 150,000 Americans headed overseas for surgical procedures, estimated Josef Woodward, author of “Patients Without Borders: Everybody's Guide to Affordable, World-Class Medical Tourism” (Chapel Hill, N.C.: Healthy Travel Media, 2007) the first, but surely not the last, popular book on the subject. His estimate is conservative: some observers put the number at closer to half a million.

Roughly 60,000 Americans have sought care at Bumrungrad International in Bangkok, widely recognized as one of Asia's leading hospitals, according to Curtis Schroeder, group CEO of Bumrungrad.

“Why travel to a hospital you can't even pronounce, in a country you've never visited, with doctors who have strange names you can't spell? There are several reasons: geopolitical factors; economic crises; lack of access to care, which is especially true for uninsured Americans or people from Western Europe who do not want to wait for services provided through their national health care systems; perceived lack of quality of care in their home countries; and family microeconomics,” said Mr. Schroeder, who previously was with Tenet Healthcare Systems, opening Tenet hospitals in several different countries.

Health care abroad is an appealing option for moderate-income Americans who are not insured. But even those with insurance are feeling the pinch and looking overseas. Mr. Schroeder cited a Time magazine survey indicating that 61% of uninsured Americans polled would travel 10,000 miles if they knew they could save $5,000 on a major medical procedure. Among those with insurance, the number was 40%.

“These are the first wave of medical tourists,” he said.

U.S. Standards … Better

According to Ori Karev, head of UnitedHealthGroup's Ovations program to improve health in people over age 50 years, there are 110 hospitals around the world accredited by the Joint Commission International, that provide as good if not better quality health care than what is available at top U.S. hospitals. JCI uses the same criteria as the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), and serves the same general purpose.

JCI-accredited hospitals, many of which are run as joint government-private sector partnerships provide services at far lower cost than U.S. hospitals. And American- or European-trained clinicians at JCI-accredited hospitals are performing cardiovascular surgery, organ transplants, and hip and knee replacements with outcomes equivalent to any U.S. center and adverse event rates comparable with or even substantially lower than at U.S. hospitals.

Mr. Woodward estimates Americans traveling for health care can expect to save between 15% and 85% on the cost of equivalent care in the United States. Savings vary widely with the type of procedure, the country visited, and any add-ons such as vacation time. But for most major procedures the savings are massive. (See box.)

Brazil, Costa Rica, and South Africa currently are hot destinations for cosmetic procedures; Costa Rica, Mexico, and Hungary are magnets for good, affordable dentistry, and India, Thailand, Malaysia, and Singapore are the best choices for major surgeries, including heart surgeries, organ transplants, and orthopedics, according to Mr. Woodward's book.

Friendly Care, Fine Food, Feng Shui

Doctors in Asia or Latin America spend up to an hour per consultation, and routinely offer their personal cell phone numbers to patients and their families. Concierge services, four-star meal plans, and hotel-style accommodations are the rule, and travel packages often include limousine transport to and from the airport and clinic. The generally slower pace and the traditions of hospitality found overseas also may appeal to Americans shell-shocked by the frazzling pace and impersonal nature of U.S. health care.

Before 1997, the U.S. and Europe were the major recipients of international medical travelers, while Singapore was the major hub for Asia, explained Bumrungrad's Mr. Schroeder. In 1997, the economic crises in many Asian countries made price of care much more of an issue, so more Asians began to travel beyond their home borders for care.

After the attacks of Sept. 11, 2001, an increasing number of patients from the Middle East began traveling to Asia for care. “They used to go to America or Europe, but visas became problematic, so they started going to Thailand, Singapore, and India,” Mr. Schroeder said.

Medical Outsourcing

According to Mr. Schroeder, “health care costs are capsizing American businesses. They're starting to look at international health care as a form of outsourcing.”

He noted that Bumrungrad recently signed a landmark deal with Blue Cross of South Carolina for a program called Companion Global Healthcare, which would provide an alternative for people wishing to seek overseas health care.

“It is essentially a pilot project. There's no commercial insurance product attached to it yet,” Mr. Schroeder said. The program provides subscribers with access to a specialized travel agency in Virginia that makes all arrangements for medical travel to Bumrungrad, and coordinates after-care through a network of South Carolina physicians.

But it is only a matter of time before U.S. insurers start actively driving patients overseas, predicted Jeffrey Lefko, a Chicago-based health care consultant who is working with Parkway Group Healthcare, a Singapore-based hospital system, to develop its U.S. referral base.

“A number of U.S. companies have started to work with self-insured plans to make procedures in Singapore a viable option. You're going to see much more of the insurance industry get interested in this,” Mr. Lefko said in an interview.

Further growth of medical travel, especially if pushed from the home front by U.S. insurers, could have a major impact on American health care systems, but Dr. Jason Chin Huat Yap, medical director of the Singapore Tourism Board, said he believes a lot of the unease surrounding these trends is unwarranted.

“Singapore's share of the global health care economy is about $12.6 billion. The U.S. share is about $2,000 billion. Even if you quadrupled our capacity and you threw in India, too, we're not even able to come close to providing health care for all Americans. It's still a very small fraction,” he said at the World Health Care Congress.

He added that a little bit of healthy competition from abroad, “could have a potentially positive structural impact on how the U.S. delivers health care services.”

Mr. Lefko said he believes the emergence of world-class health care systems across the Pacific will likely give U.S. hospitals and clinics a much-needed kick in the bedpan.

“Already 500,000 Americans each year are leaving the U.S. for health care reasons, and this is going to grow. U.S. hospitals and doctors will complain, but the reality is, U.S. hospitals have had plenty of time to straighten out their acts. They've had plenty of opportunities to create better, more economical health care services. Medical tourism's going to level the playing field. I've been in the hospital business for 35 years, and I've seen all sorts of facilities and operations,” Mr. Lefko said. “I wouldn't hesitate to go to any of the hospitals in Singapore.”

A Medical Travel Hot Spot: Singapore

When it comes to medical travel, Singapore presents a classic case of supply and demand, Dr. Yap said at the World Health Care Congress.

Singapore's tertiary-care hospitals have excess capacity that they're trying to fill. “We have a very small population, and on our own we are not able to maintain the state-of-the-art services. So our approach is to fill the service volume with international patients. That way we can acquire the technology, keep the subspecialists, and provide the highest quality services. We're led by the Ministry of Health in this. It is not just an economic enterprise, it is about providing quality health care for everyone,” said Dr. Yap, medical director of the Singapore Tourism Board.

Singapore's hospitals are considered the best in Asia, and the sixth best in the world. “We have one-third of all the JCI accredited facilities, and JCI standards are equivalent or even more stringent than JCAHO's,” Dr. Yap said. “We have lower ICU/CCU infection rates than many centers in the U.S. cities. Health care in Singapore is on par with most U.S. hospitals or better.”

Kamaljeet Singh Gill, general manager of the National Health Care Group, representing several tertiary-care centers in Singapore, explained that his country has a national single-payer health care system, with tiered pricing based on need. “If you have money you pay, if you do not have money you don't pay.” All hospitals in the country are government owned, and they're equivalent to the Mayo Clinic, “but much less expensive.”

Each hospital in Singapore serves about 1 million people annually, 1% of whom are international patients. He said Americans are still in the minority, representing only about 20% of all international business. But the number is growing. “Even without major marketing effort, we're seeing an increase in U.S. and U.K. patients.”

He stressed that his group is not competing with India or Thailand, and is not promoting “medical tourism,” but rather comprehensive affordable state-of-the-art medical services. In addition to treatment and procedures, hospitals in Singapore offer international visitors a wide range of holistic health services, fresh healthy Asian-style food, art and music therapies, and well-designed healing environments of a sort rarely found in U.S. facilities.

Dr. Yap added that this approach represents a strong shift away from the stereotype of medical tourism, which used to mean elective or commodity surgery at facilities with uncertain quality records, questionable marketing methods, and an absence of care continuity.

“Medical travel involves patients going abroad for needed medical care, with minimal leisure components. This is essential health care that, for whatever reason, the individual cannot access at home,” he stressed that medical teams in Singapore endeavor to be part of the normal care continuum and to develop good interconnectivity with the patient's doctors at home. “We prefer that physicians in the patients' home country refer the patient to us. We're not trying to pull patients away from their home doctors.”

WASHINGTON — The emergence of medical centers in Asia, Latin America, and Eastern Europe that provide state-of-the-art procedures with a human touch and a gentle price tag has many U.S. citizens flying abroad to seek care they might have gotten at their local hospitals.

Medical travel—don't call it medical tourism anymore—has grown rapidly in recent years. In principle, there's nothing really new about it. For years, wealthy individuals from all over the world have flown to the United States or Western Europe for advanced procedures not available at home.

What is new is the ease of medical travel, the numbers of people getting treated away from home, and the direction: away from the United States and toward Asia, Eastern Europe, and Latin America.

Last year, roughly 150,000 Americans headed overseas for surgical procedures, estimated Josef Woodward, author of “Patients Without Borders: Everybody's Guide to Affordable, World-Class Medical Tourism” (Chapel Hill, N.C.: Healthy Travel Media, 2007), the first, but surely not the last, popular book on the subject. His estimate is conservative: Some observers put the number at closer to half a million.

Roughly 60,000 Americans have sought care at Bumrungrad International in Bangkok, widely recognized as one of Asia's leading hospitals, according to Curtis Schroeder, group CEO of Bumrungrad.

“Why travel to a hospital you can't even pronounce, in a country you've never visited, with doctors who have strange names you can't spell? There are several reasons: geopolitical factors; economic crises; lack of access to care, which is especially true for uninsured Americans or people from Western Europe who do not want to wait for services provided through their national health care systems; perceived lack of quality of care in their home countries; and family microeconomics,” said Mr. Schroeder, who previously was with Tenet Healthcare Systems, opening Tenet hospitals in several different countries.

Health care abroad is an appealing option for moderate-income Americans who are not insured. But even those with insurance are feeling the pinch and looking overseas. Mr. Schroeder cited a Time magazine survey indicating that 61% of uninsured Americans polled would travel 10,000 miles if they knew they could save $5,000 on a major medical procedure. Among those with insurance, the number was 40%.

“These are the first wave of medical tourists,” he said.

U.S. Standards…Better

According to Ori Karev, head of UnitedHealthGroup's Ovations program to improve health in people over age 50 years, there are 110 hospitals around the world accredited by the Joint Commission International that provide as good if not better quality health care than what is available at top U.S. hospitals. JCI uses the same criteria as the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) and serves the same general purpose.

The International Organisation for Standardization, a 157-nation network of accrediting institutions based in Geneva, also accredits hospitals and clinics abroad but focuses mainly on facilities management and administration, not clinical measures. “While ISO accreditation is good to see, it is of limited value in terms of treatment,” according to Mr. Woodward's book.

JCI-accredited hospitals, many of which are run as joint government-private sector partnerships, are typically founded on the relatively solid economic bedrock of national single-payer health systems. They provide services at far lower cost than U.S. hospitals in part because the surrounding social and cultural milieu is relatively free of many of the cost drivers in the U.S. system: insurance bureaucracy, tort law, high malpractice settlements, entitlement mentality, and deficit-spending lifestyles.

Once largely confined to elective cosmetic procedures or experimental treatments, medical travel now encompasses everything one would expect at an American or European tertiary-care center, including cardiovascular surgery, organ transplants, hip and knee replacements, and advanced cancer therapies. American- or European-trained clinicians at JCI-accredited hospitals are performing such procedures with outcomes equivalent to any U.S. center, adverse event rates comparable or even substantially lower than at U.S. hospitals, and markedly reduced costs.

Mr. Woodward estimates Americans traveling for health care can expect to save between 15% and 85% on the cost of equivalent care in the United States. Savings vary widely with the type of procedure, the country visited, and any add-ons such as vacation time. But for most major procedures the savings are massive. (See box.)

Brazil, Costa Rica, and South Africa currently are hot destinations for cosmetic procedures; Costa Rica, Mexico, and Hungary are magnets for good, affordable dentistry; and India, Thailand, Malaysia, and Singapore are the best choices for major surgeries, including heart surgeries, organ transplants, and orthopedics, according to Mr. Woodward's book.

Friendly Care, Fine Food, Feng Shui

Cost savings are a primary driver, but it is more than simple economics that attract Americans abroad. Leading international clinics can provide levels of service and comfort almost unheard of in U.S. hospitals.

Doctors in Asia or Latin America spend up to an hour per consultation, and routinely offer their personal cell phone numbers to patients and their families. Concierge services, four-star meal plans, and hotel-style accommodations are the rule, and travel packages often include limousine transport to and from the airport and clinic. The generally slower pace and the traditions of hospitality found overseas also may appeal to Americans shell-shocked by the frazzling pace and impersonal nature of U.S. health care.

Before 1997, the United States and Europe were the major recipients of international medical travelers, while Singapore was the major hub for Asia, explained Bumrungrad's Mr. Schroeder. In 1997, the economic crises in many Asian countries made price of care much more of an issue, so more Asians began to travel beyond their home borders for care.

After the attacks of Sept. 11, 2001, an increasing number of patients from the Middle East began traveling to Asia for care. “They used to go to America or Europe, but visas became problematic, so they started going to Thailand, Singapore, and India,” Mr. Schroeder said. He estimated Bumrungrad served 92,000 people from Middle Eastern countries in the past year, representing about 20% of total international business for the hospital.

In response to the influx of investment capital and international patient volume, hospitals in Thailand, India, and Singapore quickly ramped up their services. They built new facilities, installed state-of-the-art technology, sent physicians abroad for training in advanced therapeutics, and recruited clinicians from abroad.

The Bugbear of Aftercare

Follow-up and recourse if there are complications are a major concern to all involved with medical travel, and it is the aspect of this trend that makes American doctors most nervous.

“It's a very legitimate concern,” Mr. Schroeder agreed. “A lot of the referrals to our hospital do not come from doctors because the patients do not have doctors. They're either outside their home health care systems (i.e., they are uninsured), or they are abandoning their home health care systems. Whenever we can, we do coordinate electronically with our patients' home doctors. If there are complications, we fly patients back, at our own expense, to take care of the problem. We do hold ourselves accountable for complications.”

Medical Outsourcing

According to Mr. Schroeder, “health care costs are capsizing American businesses. They're starting to look at international health care as a form of outsourcing..”

He noted that Bumrungrad recently signed a landmark deal with Blue Cross of South Carolina for a program called Companion Global Healthcare, which would provide an alternative for people wishing to seek overseas health care.

“It is essentially a pilot project. There's no commercial insurance product attached to it yet,” Mr. Schroeder said. The program provides subscribers with access to a specialized travel agency in Virginia that makes all arrangements for medical travel to Bumrungrad, and coordinates aftercare through a network of South Carolina physicians.

But it is only a matter of time before U.S. insurers start actively driving patients overseas, predicted Jeffrey Lefko, a Chicago-based health care consultant who is working with Parkway Group Healthcare, a Singapore-based hospital system, to develop its U.S. referral base.

“A number of U.S. companies have started to work with self-insured plans to make procedures in Singapore a viable option. You're going to see much more of the insurance industry get interested in this,” Mr. Lefko said in an interview.

Further growth of medical travel, especially if pushed from the home front by U.S. insurers, could have a major impact on U.S. health care systems, but Dr. Jason Chin Huat Yap, medical director of the Singapore Tourism Board, said much of the unease surrounding these trends is unwarranted.

“Singapore's share of the global health care economy is about $12.6 billion. The U.S. share is about $2,000 billion. Even if you quadrupled our capacity and you threw in India, too, we're not even able to come close to providing health care for all Americans. It's still a very small fraction,” he said at the World Health Care Congress.

Mr. Lefko added that a little bit of healthy competition from abroad “could have a potentially positive structural impact on how the U.S. delivers health care services.”

The emergence of world-class health care systems across the Pacific will likely give U.S. facilities a much-needed kick in the bedpan. “Already 500,000 Americans each year are leaving the U.S. for health care reasons, and this is going to grow,” he said. “U.S. hospitals have had plenty of time to straighten out their acts. They've had plenty of opportunities to create better, more economical health care services.

“Medical tourism's going to level the playing field. I've been in the hospital business for 35 years, and I've seen all sorts of facilities and operations. I wouldn't hesitate to go to any of the hospitals in Singapore,” Mr. Lefko said.

A Medical Travel Hot Spot: Singapore

When it comes to medical travel, Singapore presents a classic case of supply and demand, Dr. Yap said at the World Health Care Congress.

Singapore's tertiary-care hospitals have excess capacity that they're trying to fill. “We have a very small population, and on our own we are not able to maintain the state-of-the-art services. So our approach is to fill the service volume with international patients. That way we can acquire the technology, keep the subspecialists, and provide the highest quality services. We're led by the Ministry of Health in this. It is not just an economic enterprise, it is about providing quality health care for everyone,” said Dr. Yap, medical director of the Singapore Tourism Board.

Singapore's hospitals are considered the best in Asia and the sixth best in the world. “We have one-third of all the JCI-accredited facilities, and JCI standards are equivalent or even more stringent than JCAHO's,” Dr. Yap said. “We have lower ICU/CCU infection rates than many centers in the U.S. cities. Health care in Singapore is on par with most U.S. hospitals or better.”

Kamaljeet Singh Gill, general manager of the National Health Care Group, representing several tertiary-care centers in Singapore, explained that his country has a national single-payer health care system, with tiered pricing based on need. “If you have money, you pay; if you do not have money, you don't pay.” All hospitals in the country are government owned, and they're equivalent to the Mayo Clinic “but much less expensive.”

Each hospital in Singapore serves about 1 million people annually, 1% of whom are international patients. He said Americans are still in the minority, representing only about 20% of all international business. But the number is growing. “Even without major marketing effort, we're seeing an increase in U.S. and U.K. patients.”

He stressed that his group is not competing with India or Thailand, and is not promoting “medical tourism,” but rather comprehensive affordable state-of-the-art medical services. In addition to treatment and procedures, hospitals in Singapore offer international visitors a wide range of holistic health services; fresh, healthy Asian-style food; art and music therapies; and well-designed healing environments of a sort rarely found in U.S. facilities.

Dr. Yap added that this approach represents a strong shift away from the stereotype of medical tourism, which used to mean elective or commodity surgery at facilities with uncertain quality records, questionable marketing methods, and a lack of care continuity.

“Medical travel involves patients going abroad for needed medical care, with minimal leisure components. This is essential health care that, for whatever reason, the individual cannot access at home.” He stressed that medical teams in Singapore endeavor to be part of the normal care continuum and to develop good interconnectivity with the patient's doctors at home. “We prefer that physicians in the patients' home country refer the patient to us. We're not trying to pull patients away from their home doctors.”

This Month's Talk Back Question

How do you view the trend of U.S. patients seeking lower-cost medical care in other countries?

WASHINGTON — The emergence of medical centers in Asia, Latin America, and Eastern Europe that provide state-of-the-art procedures with a human touch and a gentle price tag has many U.S. citizens flying abroad to seek care they might have gotten at their local hospitals.

Medical travel—don't call it medical tourism anymore—has grown rapidly in recent years. In principle, there's nothing really new about it. For years, wealthy individuals from all over the world have flown to the United States or Western Europe for advanced procedures not available at home.

What is new is the ease of medical travel, the numbers of people getting treated away from home, and the direction: away from the United States and toward Asia, Eastern Europe, and Latin America.

Last year, roughly 150,000 Americans headed overseas for surgical procedures, estimated Josef Woodward, author of “Patients Without Borders: Everybody's Guide to Affordable, World-Class Medical Tourism” (Chapel Hill, N.C.: Healthy Travel Media, 2007), the first, but surely not the last, popular book on the subject. His estimate is conservative: Some observers put the number at closer to half a million.

Roughly 60,000 Americans have sought care at Bumrungrad International in Bangkok, widely recognized as one of Asia's leading hospitals, according to Curtis Schroeder, group CEO of Bumrungrad.

“Why travel to a hospital you can't even pronounce, in a country you've never visited, with doctors who have strange names you can't spell? There are several reasons: geopolitical factors; economic crises; lack of access to care, which is especially true for uninsured Americans or people from Western Europe who do not want to wait for services provided through their national health care systems; perceived lack of quality of care in their home countries; and family microeconomics,” said Mr. Schroeder, who previously was with Tenet Healthcare Systems, opening Tenet hospitals in several different countries.

Health care abroad is an appealing option for moderate-income Americans who are not insured. But even those with insurance are feeling the pinch and looking overseas. Mr. Schroeder cited a Time magazine survey indicating that 61% of uninsured Americans polled would travel 10,000 miles if they knew they could save $5,000 on a major medical procedure. Among those with insurance, the number was 40%.

“These are the first wave of medical tourists,” he said.

U.S. Standards…Better

According to Ori Karev, head of UnitedHealthGroup's Ovations program to improve health in people over age 50 years, there are 110 hospitals around the world accredited by the Joint Commission International that provide as good if not better quality health care than what is available at top U.S. hospitals. JCI uses the same criteria as the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) and serves the same general purpose.

The International Organisation for Standardization, a 157-nation network of accrediting institutions based in Geneva, also accredits hospitals and clinics abroad but focuses mainly on facilities management and administration, not clinical measures. “While ISO accreditation is good to see, it is of limited value in terms of treatment,” according to Mr. Woodward's book.

JCI-accredited hospitals, many of which are run as joint government-private sector partnerships, are typically founded on the relatively solid economic bedrock of national single-payer health systems. They provide services at far lower cost than U.S. hospitals in part because the surrounding social and cultural milieu is relatively free of many of the cost drivers in the U.S. system: insurance bureaucracy, tort law, high malpractice settlements, entitlement mentality, and deficit-spending lifestyles.

Once largely confined to elective cosmetic procedures or experimental treatments, medical travel now encompasses everything one would expect at an American or European tertiary-care center, including cardiovascular surgery, organ transplants, hip and knee replacements, and advanced cancer therapies. American- or European-trained clinicians at JCI-accredited hospitals are performing such procedures with outcomes equivalent to any U.S. center, adverse event rates comparable or even substantially lower than at U.S. hospitals, and markedly reduced costs.

Mr. Woodward estimates Americans traveling for health care can expect to save between 15% and 85% on the cost of equivalent care in the United States. Savings vary widely with the type of procedure, the country visited, and any add-ons such as vacation time. But for most major procedures the savings are massive. (See box.)

Brazil, Costa Rica, and South Africa currently are hot destinations for cosmetic procedures; Costa Rica, Mexico, and Hungary are magnets for good, affordable dentistry; and India, Thailand, Malaysia, and Singapore are the best choices for major surgeries, including heart surgeries, organ transplants, and orthopedics, according to Mr. Woodward's book.

Friendly Care, Fine Food, Feng Shui

Cost savings are a primary driver, but it is more than simple economics that attract Americans abroad. Leading international clinics can provide levels of service and comfort almost unheard of in U.S. hospitals.

Doctors in Asia or Latin America spend up to an hour per consultation, and routinely offer their personal cell phone numbers to patients and their families. Concierge services, four-star meal plans, and hotel-style accommodations are the rule, and travel packages often include limousine transport to and from the airport and clinic. The generally slower pace and the traditions of hospitality found overseas also may appeal to Americans shell-shocked by the frazzling pace and impersonal nature of U.S. health care.

Before 1997, the United States and Europe were the major recipients of international medical travelers, while Singapore was the major hub for Asia, explained Bumrungrad's Mr. Schroeder. In 1997, the economic crises in many Asian countries made price of care much more of an issue, so more Asians began to travel beyond their home borders for care.

After the attacks of Sept. 11, 2001, an increasing number of patients from the Middle East began traveling to Asia for care. “They used to go to America or Europe, but visas became problematic, so they started going to Thailand, Singapore, and India,” Mr. Schroeder said. He estimated Bumrungrad served 92,000 people from Middle Eastern countries in the past year, representing about 20% of total international business for the hospital.

In response to the influx of investment capital and international patient volume, hospitals in Thailand, India, and Singapore quickly ramped up their services. They built new facilities, installed state-of-the-art technology, sent physicians abroad for training in advanced therapeutics, and recruited clinicians from abroad.

The Bugbear of Aftercare

Follow-up and recourse if there are complications are a major concern to all involved with medical travel, and it is the aspect of this trend that makes American doctors most nervous.

“It's a very legitimate concern,” Mr. Schroeder agreed. “A lot of the referrals to our hospital do not come from doctors because the patients do not have doctors. They're either outside their home health care systems (i.e., they are uninsured), or they are abandoning their home health care systems. Whenever we can, we do coordinate electronically with our patients' home doctors. If there are complications, we fly patients back, at our own expense, to take care of the problem. We do hold ourselves accountable for complications.”

Medical Outsourcing

According to Mr. Schroeder, “health care costs are capsizing American businesses. They're starting to look at international health care as a form of outsourcing..”

He noted that Bumrungrad recently signed a landmark deal with Blue Cross of South Carolina for a program called Companion Global Healthcare, which would provide an alternative for people wishing to seek overseas health care.

“It is essentially a pilot project. There's no commercial insurance product attached to it yet,” Mr. Schroeder said. The program provides subscribers with access to a specialized travel agency in Virginia that makes all arrangements for medical travel to Bumrungrad, and coordinates aftercare through a network of South Carolina physicians.

But it is only a matter of time before U.S. insurers start actively driving patients overseas, predicted Jeffrey Lefko, a Chicago-based health care consultant who is working with Parkway Group Healthcare, a Singapore-based hospital system, to develop its U.S. referral base.

“A number of U.S. companies have started to work with self-insured plans to make procedures in Singapore a viable option. You're going to see much more of the insurance industry get interested in this,” Mr. Lefko said in an interview.

Further growth of medical travel, especially if pushed from the home front by U.S. insurers, could have a major impact on U.S. health care systems, but Dr. Jason Chin Huat Yap, medical director of the Singapore Tourism Board, said much of the unease surrounding these trends is unwarranted.

“Singapore's share of the global health care economy is about $12.6 billion. The U.S. share is about $2,000 billion. Even if you quadrupled our capacity and you threw in India, too, we're not even able to come close to providing health care for all Americans. It's still a very small fraction,” he said at the World Health Care Congress.

Mr. Lefko added that a little bit of healthy competition from abroad “could have a potentially positive structural impact on how the U.S. delivers health care services.”

The emergence of world-class health care systems across the Pacific will likely give U.S. facilities a much-needed kick in the bedpan. “Already 500,000 Americans each year are leaving the U.S. for health care reasons, and this is going to grow,” he said. “U.S. hospitals have had plenty of time to straighten out their acts. They've had plenty of opportunities to create better, more economical health care services.

“Medical tourism's going to level the playing field. I've been in the hospital business for 35 years, and I've seen all sorts of facilities and operations. I wouldn't hesitate to go to any of the hospitals in Singapore,” Mr. Lefko said.

A Medical Travel Hot Spot: Singapore

When it comes to medical travel, Singapore presents a classic case of supply and demand, Dr. Yap said at the World Health Care Congress.

Singapore's tertiary-care hospitals have excess capacity that they're trying to fill. “We have a very small population, and on our own we are not able to maintain the state-of-the-art services. So our approach is to fill the service volume with international patients. That way we can acquire the technology, keep the subspecialists, and provide the highest quality services. We're led by the Ministry of Health in this. It is not just an economic enterprise, it is about providing quality health care for everyone,” said Dr. Yap, medical director of the Singapore Tourism Board.

Singapore's hospitals are considered the best in Asia and the sixth best in the world. “We have one-third of all the JCI-accredited facilities, and JCI standards are equivalent or even more stringent than JCAHO's,” Dr. Yap said. “We have lower ICU/CCU infection rates than many centers in the U.S. cities. Health care in Singapore is on par with most U.S. hospitals or better.”

Kamaljeet Singh Gill, general manager of the National Health Care Group, representing several tertiary-care centers in Singapore, explained that his country has a national single-payer health care system, with tiered pricing based on need. “If you have money, you pay; if you do not have money, you don't pay.” All hospitals in the country are government owned, and they're equivalent to the Mayo Clinic “but much less expensive.”

Each hospital in Singapore serves about 1 million people annually, 1% of whom are international patients. He said Americans are still in the minority, representing only about 20% of all international business. But the number is growing. “Even without major marketing effort, we're seeing an increase in U.S. and U.K. patients.”

He stressed that his group is not competing with India or Thailand, and is not promoting “medical tourism,” but rather comprehensive affordable state-of-the-art medical services. In addition to treatment and procedures, hospitals in Singapore offer international visitors a wide range of holistic health services; fresh, healthy Asian-style food; art and music therapies; and well-designed healing environments of a sort rarely found in U.S. facilities.

Dr. Yap added that this approach represents a strong shift away from the stereotype of medical tourism, which used to mean elective or commodity surgery at facilities with uncertain quality records, questionable marketing methods, and a lack of care continuity.

“Medical travel involves patients going abroad for needed medical care, with minimal leisure components. This is essential health care that, for whatever reason, the individual cannot access at home.” He stressed that medical teams in Singapore endeavor to be part of the normal care continuum and to develop good interconnectivity with the patient's doctors at home. “We prefer that physicians in the patients' home country refer the patient to us. We're not trying to pull patients away from their home doctors.”

This Month's Talk Back Question

How do you view the trend of U.S. patients seeking lower-cost medical care in other countries?

WASHINGTON — The emergence of medical centers in Asia, Latin America, and Eastern Europe that provide state-of-the-art procedures with a human touch and a gentle price tag has many U.S. citizens flying abroad to seek care they might have gotten at their local hospitals.

Medical travel—don't call it medical tourism anymore—has grown rapidly in recent years. In principle, there's nothing really new about it. For years, wealthy individuals from all over the world have flown to the United States or Western Europe for advanced procedures not available at home.

What is new is the ease of medical travel, the numbers of people getting treated away from home, and the direction: away from the United States and toward Asia, Eastern Europe, and Latin America.

Last year, roughly 150,000 Americans headed overseas for surgical procedures, estimated Josef Woodward, author of “Patients Without Borders: Everybody's Guide to Affordable, World-Class Medical Tourism” (Chapel Hill, N.C.: Healthy Travel Media, 2007), the first, but surely not the last, popular book on the subject. His estimate is conservative: Some observers put the number at closer to half a million.

Roughly 60,000 Americans have sought care at Bumrungrad International in Bangkok, widely recognized as one of Asia's leading hospitals, according to Curtis Schroeder, group CEO of Bumrungrad.

“Why travel to a hospital you can't even pronounce, in a country you've never visited, with doctors who have strange names you can't spell? There are several reasons: geopolitical factors; economic crises; lack of access to care, which is especially true for uninsured Americans or people from Western Europe who do not want to wait for services provided through their national health care systems; perceived lack of quality of care in their home countries; and family microeconomics,” said Mr. Schroeder, who previously was with Tenet Healthcare Systems, opening Tenet hospitals in several different countries.

Health care abroad is an appealing option for moderate-income Americans who are not insured. But even those with insurance are feeling the pinch and looking overseas. Mr. Schroeder cited a Time magazine survey indicating that 61% of uninsured Americans polled would travel 10,000 miles if they knew they could save $5,000 on a major medical procedure. Among those with insurance, the number was 40%.

“These are the first wave of medical tourists,” he said.

U.S. Standards…Better

According to Ori Karev, head of UnitedHealthGroup's Ovations program to improve health in people over age 50 years, there are 110 hospitals around the world accredited by the Joint Commission International that provide as good if not better quality health care than what is available at top U.S. hospitals. JCI uses the same criteria as the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) and serves the same general purpose.

The International Organisation for Standardization, a 157-nation network of accrediting institutions based in Geneva, also accredits hospitals and clinics abroad but focuses mainly on facilities management and administration, not clinical measures. “While ISO accreditation is good to see, it is of limited value in terms of treatment,” according to Mr. Woodward's book.

JCI-accredited hospitals, many of which are run as joint government-private sector partnerships, are typically founded on the relatively solid economic bedrock of national single-payer health systems. They provide services at far lower cost than U.S. hospitals in part because the surrounding social and cultural milieu is relatively free of many of the cost drivers in the U.S. system: insurance bureaucracy, tort law, high malpractice settlements, entitlement mentality, and deficit-spending lifestyles.

Once largely confined to elective cosmetic procedures or experimental treatments, medical travel now encompasses everything one would expect at an American or European tertiary-care center, including cardiovascular surgery, organ transplants, hip and knee replacements, and advanced cancer therapies. American- or European-trained clinicians at JCI-accredited hospitals are performing such procedures with outcomes equivalent to any U.S. center, adverse event rates comparable or even substantially lower than at U.S. hospitals, and markedly reduced costs.

Mr. Woodward estimates Americans traveling for health care can expect to save between 15% and 85% on the cost of equivalent care in the United States. Savings vary widely with the type of procedure, the country visited, and any add-ons such as vacation time. But for most major procedures the savings are massive. (See box.)

Brazil, Costa Rica, and South Africa currently are hot destinations for cosmetic procedures; Costa Rica, Mexico, and Hungary are magnets for good, affordable dentistry; and India, Thailand, Malaysia, and Singapore are the best choices for major surgeries, including heart surgeries, organ transplants, and orthopedics, according to Mr. Woodward's book.

Friendly Care, Fine Food, Feng Shui

Cost savings are a primary driver, but it is more than simple economics that attract Americans abroad. Leading international clinics can provide levels of service and comfort almost unheard of in U.S. hospitals.

Doctors in Asia or Latin America spend up to an hour per consultation, and routinely offer their personal cell phone numbers to patients and their families. Concierge services, four-star meal plans, and hotel-style accommodations are the rule, and travel packages often include limousine transport to and from the airport and clinic. The generally slower pace and the traditions of hospitality found overseas also may appeal to Americans shell-shocked by the frazzling pace and impersonal nature of U.S. health care.

Before 1997, the United States and Europe were the major recipients of international medical travelers, while Singapore was the major hub for Asia, explained Bumrungrad's Mr. Schroeder. In 1997, the economic crises in many Asian countries made price of care much more of an issue, so more Asians began to travel beyond their home borders for care.

After the attacks of Sept. 11, 2001, an increasing number of patients from the Middle East began traveling to Asia for care. “They used to go to America or Europe, but visas became problematic, so they started going to Thailand, Singapore, and India,” Mr. Schroeder said. He estimated Bumrungrad served 92,000 people from Middle Eastern countries in the past year, representing about 20% of total international business for the hospital.

In response to the influx of investment capital and international patient volume, hospitals in Thailand, India, and Singapore quickly ramped up their services. They built new facilities, installed state-of-the-art technology, sent physicians abroad for training in advanced therapeutics, and recruited clinicians from abroad.

The Bugbear of Aftercare

Follow-up and recourse if there are complications are a major concern to all involved with medical travel, and it is the aspect of this trend that makes American doctors most nervous.

“It's a very legitimate concern,” Mr. Schroeder agreed. “A lot of the referrals to our hospital do not come from doctors because the patients do not have doctors. They're either outside their home health care systems (i.e., they are uninsured), or they are abandoning their home health care systems. Whenever we can, we do coordinate electronically with our patients' home doctors. If there are complications, we fly patients back, at our own expense, to take care of the problem. We do hold ourselves accountable for complications.”

Medical Outsourcing

According to Mr. Schroeder, “health care costs are capsizing American businesses. They're starting to look at international health care as a form of outsourcing..”

He noted that Bumrungrad recently signed a landmark deal with Blue Cross of South Carolina for a program called Companion Global Healthcare, which would provide an alternative for people wishing to seek overseas health care.

“It is essentially a pilot project. There's no commercial insurance product attached to it yet,” Mr. Schroeder said. The program provides subscribers with access to a specialized travel agency in Virginia that makes all arrangements for medical travel to Bumrungrad, and coordinates aftercare through a network of South Carolina physicians.

But it is only a matter of time before U.S. insurers start actively driving patients overseas, predicted Jeffrey Lefko, a Chicago-based health care consultant who is working with Parkway Group Healthcare, a Singapore-based hospital system, to develop its U.S. referral base.

“A number of U.S. companies have started to work with self-insured plans to make procedures in Singapore a viable option. You're going to see much more of the insurance industry get interested in this,” Mr. Lefko said in an interview.

Further growth of medical travel, especially if pushed from the home front by U.S. insurers, could have a major impact on U.S. health care systems, but Dr. Jason Chin Huat Yap, medical director of the Singapore Tourism Board, said much of the unease surrounding these trends is unwarranted.

“Singapore's share of the global health care economy is about $12.6 billion. The U.S. share is about $2,000 billion. Even if you quadrupled our capacity and you threw in India, too, we're not even able to come close to providing health care for all Americans. It's still a very small fraction,” he said at the World Health Care Congress.

Mr. Lefko added that a little bit of healthy competition from abroad “could have a potentially positive structural impact on how the U.S. delivers health care services.”

The emergence of world-class health care systems across the Pacific will likely give U.S. facilities a much-needed kick in the bedpan. “Already 500,000 Americans each year are leaving the U.S. for health care reasons, and this is going to grow,” he said. “U.S. hospitals have had plenty of time to straighten out their acts. They've had plenty of opportunities to create better, more economical health care services.

“Medical tourism's going to level the playing field. I've been in the hospital business for 35 years, and I've seen all sorts of facilities and operations. I wouldn't hesitate to go to any of the hospitals in Singapore,” Mr. Lefko said.

A Medical Travel Hot Spot: Singapore

When it comes to medical travel, Singapore presents a classic case of supply and demand, Dr. Yap said at the World Health Care Congress.

Singapore's tertiary-care hospitals have excess capacity that they're trying to fill. “We have a very small population, and on our own we are not able to maintain the state-of-the-art services. So our approach is to fill the service volume with international patients. That way we can acquire the technology, keep the subspecialists, and provide the highest quality services. We're led by the Ministry of Health in this. It is not just an economic enterprise, it is about providing quality health care for everyone,” said Dr. Yap, medical director of the Singapore Tourism Board.

Singapore's hospitals are considered the best in Asia and the sixth best in the world. “We have one-third of all the JCI-accredited facilities, and JCI standards are equivalent or even more stringent than JCAHO's,” Dr. Yap said. “We have lower ICU/CCU infection rates than many centers in the U.S. cities. Health care in Singapore is on par with most U.S. hospitals or better.”

Kamaljeet Singh Gill, general manager of the National Health Care Group, representing several tertiary-care centers in Singapore, explained that his country has a national single-payer health care system, with tiered pricing based on need. “If you have money, you pay; if you do not have money, you don't pay.” All hospitals in the country are government owned, and they're equivalent to the Mayo Clinic “but much less expensive.”

Each hospital in Singapore serves about 1 million people annually, 1% of whom are international patients. He said Americans are still in the minority, representing only about 20% of all international business. But the number is growing. “Even without major marketing effort, we're seeing an increase in U.S. and U.K. patients.”

He stressed that his group is not competing with India or Thailand, and is not promoting “medical tourism,” but rather comprehensive affordable state-of-the-art medical services. In addition to treatment and procedures, hospitals in Singapore offer international visitors a wide range of holistic health services; fresh, healthy Asian-style food; art and music therapies; and well-designed healing environments of a sort rarely found in U.S. facilities.

Dr. Yap added that this approach represents a strong shift away from the stereotype of medical tourism, which used to mean elective or commodity surgery at facilities with uncertain quality records, questionable marketing methods, and a lack of care continuity.

“Medical travel involves patients going abroad for needed medical care, with minimal leisure components. This is essential health care that, for whatever reason, the individual cannot access at home.” He stressed that medical teams in Singapore endeavor to be part of the normal care continuum and to develop good interconnectivity with the patient's doctors at home. “We prefer that physicians in the patients' home country refer the patient to us. We're not trying to pull patients away from their home doctors.”

This Month's Talk Back Question

How do you view the trend of U.S. patients seeking lower-cost medical care in other countries?

WASHINGTON — The emergence of medical centers in Asia, Latin America, and Eastern Europe that provide state-of-the-art procedures with a human touch and a gentle price tag has many U.S. citizens flying abroad to seek care they might have gotten at their local hospitals.

Medical travel—don't call it medical tourism anymore—has increased rapidly in recent years. In principle, there's nothing really new about it. For years, wealthy individuals from all over the world have flown to the United States or Western Europe for advanced procedures not available at home.

What is new is the ease of medical travel, the numbers of people getting treated away from home, and the direction: away from the United States and toward Asia, Eastern Europe, and Latin America.

Last year, roughly 150,000 Americans headed overseas for surgical procedures, estimated Josef Woodward, author of “Patients Without Borders: Everybody's Guide to Affordable, World-Class Medical Tourism” (Chapel Hill, N.C.: Healthy Travel Media, 2007), the first, but surely not the last, popular book on the subject. His estimate is conservative: Some observers put the number at closer to half a million.

Roughly 60,000 Americans have sought care at Bumrungrad International in Bangkok, widely recognized as one of Asia's leading hospitals, according to Curtis Schroeder, group CEO of Bumrungrad.

“Why travel to a hospital you can't even pronounce, in a country you've never visited, with doctors who have strange names you can't spell? There are several reasons: geopolitical factors; economic crises; lack of access to care, which is especially true for uninsured Americans or people from Western Europe who do not want to wait for services provided through their national health care systems; perceived lack of quality of care in their home countries; and family microeconomics,” said Mr. Schroeder, who previously was with Tenet Healthcare Systems, opening Tenet hospitals in several different countries.

Health care abroad is an appealing option for moderate-income Americans who are not insured. But even those with insurance are feeling the pinch and looking overseas. Mr. Schroeder cited a Time magazine survey indicating that 61% of uninsured Americans polled would travel 10,000 miles if they knew they could save $5,000 on a major medical procedure. Among those with insurance, the number was 40%.

“These are the first wave of medical tourists,” he said.

U.S. Standards … Better

According to Ori Karev, head of UnitedHealthGroup's Ovations program to improve health in people over age 50 years, there are 110 hospitals around the world accredited by the Joint Commission International that provide as good if not better quality health care than do top U.S. hospitals. JCI uses the same criteria as the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), and serves the same general purpose.

The International Organisation for Standardization, a 157-nation network of accrediting institutions based in Geneva, also accredits hospitals and clinics abroad, but focuses mainly on facilities management and administration, not clinical measures. “While ISO accreditation is good to see, it is of limited value in terms of treatment,” according to Mr. Woodward's book.

JCI-accredited hospitals, many of which are run as joint government-private sector partnerships, are typically founded on the relatively solid economic bedrock of national single-payer health systems. They provide services at far lower cost than U.S. hospitals in part because the surrounding social and cultural milieu is relatively free from many of the cost drivers in the U.S. system: insurance bureaucracy, tort law, high malpractice settlements, entitlement mentality, and deficit-spending lifestyles.

Once largely confined to elective cosmetic procedures or experimental treatments, medical travel now encompasses everything one would expect at an American or European tertiary-care center, including cardiovascular surgery, organ transplants, hip and knee replacements, and advanced cancer therapies. American- or European-trained clinicians at JCI-accredited hospitals are performing such procedures with outcomes equivalent to any U.S. center, with adverse event rates comparable or even substantially lower than at U.S. hospitals, and at markedly reduced costs.

Mr. Woodward estimates Americans traveling for health care can expect to save between 15% and 85% on the cost of equivalent care in the United States. Savings vary widely with the type of procedure, the country visited, and any add-ons such as vacation time. But for most major procedures the savings are massive.

Brazil, Costa Rica, and South Africa currently are hot destinations for cosmetic procedures; Costa Rica, Mexico, and Hungary are magnets for good, affordable dentistry; and India, Thailand, Malaysia, and Singapore are the best choices for major surgeries, including heart surgeries, organ transplants, and orthopedics, according to Mr. Woodward's book.

Friendly Physicians, Fine Food, and Feng Shui

Cost savings are a primary driver, but it is more than simple economics that attract Americans abroad. The leading international clinics can provide levels of service and comfort almost unheard of in U.S. hospitals.

Doctors in Asia or Latin America spend up to an hour per consultation, and routinely offer their personal cell phone numbers to patients and their families. Concierge services, four-star meal plans, and hotel-style accommodations are the rule, and travel packages often include limousine transport to and from the airport and clinic. The generally slower pace and the traditions of hospitality found overseas also may appeal to Americans shell-shocked by the frazzling pace and impersonal nature of U.S. health care.

Before 1997, the U.S. and Europe were the major recipients of international medical travelers, while Singapore was the major hub for Asia, explained Bumrungrad's Mr. Schroeder. In 1997, the economic crises in many Asian countries made price of care much more of an issue, so more Asians began to travel beyond their home borders for care.

After the attacks of Sept. 11, 2001, an increasing number of patients from the Middle East began traveling to Asia for care. “They used to go to America or Europe, but visas became problematic, so they started going to Thailand, Singapore, and India,” said Mr. Schroeder. He estimated Bumrungrad served 92,000 people from Middle Eastern countries in the last year; representing about 20% of total international business for the hospital.

In response to the influx of investment capital and international patient volume, hospitals in Thailand, India, and Singapore quickly ramped up their services. They built new facilities, installed state-of-the-art technology, sent physicians abroad for training in advanced therapeutics, and recruited clinicians from abroad.

The Bugbear of Aftercare

Follow-up and recourse if there are complications are a major concern to all involved with medical travel, and it is the aspect of this trend that makes American doctors most nervous.

“It's a very legitimate concern,” agreed Mr. Schroeder.

“A lot of the referrals to our hospital do not come from doctors because the patients do not have doctors. They're either outside their home health care systems (i.e., they are uninsured) or they are abandoning their home health care systems. Whenever we can, we do coordinate electronically with our patients' home doctors. If there are complications, we fly patients back, at our own expense, to take care of the problem. We do hold ourselves accountable for complications.”

Medical Outsourcing

According to Mr. Schroeder, “health care costs are capsizing American businesses. They're starting to look at international health care as a form of outsourcing. The idea, while not yet widespread, is gaining traction.”

He noted that Bumrungrad recently signed a landmark deal with Blue Cross of South Carolina, for a program called, Companion Global Healthcare, which would provide an alternative for people wishing to seek overseas health care.

“It is essentially a pilot project. There's no commercial insurance product attached to it yet. We're exploring processes. It's a learning situation. We're trying to feel it out and see if it can work,” said Mr. Schroeder.

The program provides subscribers with access to a specialized travel agency in Virginia that makes all arrangements for medical travel to Bumrungrad, and coordinates after-care through a network of South Carolina physicians.

But it is only a matter of time before U.S. insurers start actively driving patients overseas, predicted Jeffrey Lefko, a Chicago-based health care consultant who is working with Parkway Group Healthcare, a Singapore-based hospital system, to develop its U.S. referral base.

“It's not happening yet, but it is going to happen, and soon,” Mr. Lefko said in an interview. “A number of U.S. companies have started to work with self-insured plans to make procedures in Singapore a viable option. You're going to see much more of the insurance industry get interested in this.”

Further growth of medical travel, especially if pushed from the home front by U.S. insurers, could have major impact on American health care systems, but Dr. Jason Chin Huat Yap, medical director of the Singapore Tourism Board, said that he believes a lot of the unease surrounding these trends is unwarranted.

“Singapore's share of the global health care economy is about $12.6 billion. The U.S. share is about $2,000 billion. Even if you quadrupled our capacity and you threw in India, too, we're not even able to come close to providing health care for all Americans. It's still a very small fraction. There are massive supply-side constraints. If 1% of all U.S. patients came over to Singapore, it would outstrip our capacity. It's really only the first-movers who are going to benefit from this,” he said at the World Health Care Congress.

He added that a little bit of healthy competition from abroad, “could have a potentially positive structural impact on how the U.S. delivers health care services.”

Mr. Lefko said that he believes the emergence of world-class health care systems across the Pacific will likely give U.S. hospitals a much-needed kick in the bedpan.

“Already 500,000 Americans each year are leaving the U.S. for health care reasons, and this is going to grow. U.S. hospitals and doctors will complain, but the reality is U.S. hospitals have had plenty of time to straighten out their acts. They've had plenty of opportunities to create better, more economical health care services. Medical tourism's going to level the playing field. I've been in the hospital business for 35 years, and I've seen all sorts of facilities and operations. I wouldn't hesitate to go to any of the hospitals in Singapore,” Mr. Lefko said.

WASHINGTON — The emergence of medical centers in Asia, Latin America, and Eastern Europe that provide state-of-the-art procedures with a human touch and a gentle price tag has many U.S. citizens flying abroad to seek care they might have gotten at their local hospitals.

Medical travel—don't call it medical tourism anymore—has increased rapidly in recent years. In principle, there's nothing really new about it. For years, wealthy individuals from all over the world have flown to the United States or Western Europe for advanced procedures not available at home.

What is new is the ease of medical travel, the numbers of people getting treated away from home, and the direction: away from the United States and toward Asia, Eastern Europe, and Latin America.

Last year, roughly 150,000 Americans headed overseas for surgical procedures, estimated Josef Woodward, author of “Patients Without Borders: Everybody's Guide to Affordable, World-Class Medical Tourism” (Chapel Hill, N.C.: Healthy Travel Media, 2007), the first, but surely not the last, popular book on the subject. His estimate is conservative: Some observers put the number at closer to half a million.

Roughly 60,000 Americans have sought care at Bumrungrad International in Bangkok, widely recognized as one of Asia's leading hospitals, according to Curtis Schroeder, group CEO of Bumrungrad.

“Why travel to a hospital you can't even pronounce, in a country you've never visited, with doctors who have strange names you can't spell? There are several reasons: geopolitical factors; economic crises; lack of access to care, which is especially true for uninsured Americans or people from Western Europe who do not want to wait for services provided through their national health care systems; perceived lack of quality of care in their home countries; and family microeconomics,” said Mr. Schroeder, who previously was with Tenet Healthcare Systems, opening Tenet hospitals in several different countries.

Health care abroad is an appealing option for moderate-income Americans who are not insured. But even those with insurance are feeling the pinch and looking overseas. Mr. Schroeder cited a Time magazine survey indicating that 61% of uninsured Americans polled would travel 10,000 miles if they knew they could save $5,000 on a major medical procedure. Among those with insurance, the number was 40%.

“These are the first wave of medical tourists,” he said.

U.S. Standards … Better

According to Ori Karev, head of UnitedHealthGroup's Ovations program to improve health in people over age 50 years, there are 110 hospitals around the world accredited by the Joint Commission International that provide as good if not better quality health care than do top U.S. hospitals. JCI uses the same criteria as the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), and serves the same general purpose.

The International Organisation for Standardization, a 157-nation network of accrediting institutions based in Geneva, also accredits hospitals and clinics abroad, but focuses mainly on facilities management and administration, not clinical measures. “While ISO accreditation is good to see, it is of limited value in terms of treatment,” according to Mr. Woodward's book.

JCI-accredited hospitals, many of which are run as joint government-private sector partnerships, are typically founded on the relatively solid economic bedrock of national single-payer health systems. They provide services at far lower cost than U.S. hospitals in part because the surrounding social and cultural milieu is relatively free from many of the cost drivers in the U.S. system: insurance bureaucracy, tort law, high malpractice settlements, entitlement mentality, and deficit-spending lifestyles.

Once largely confined to elective cosmetic procedures or experimental treatments, medical travel now encompasses everything one would expect at an American or European tertiary-care center, including cardiovascular surgery, organ transplants, hip and knee replacements, and advanced cancer therapies. American- or European-trained clinicians at JCI-accredited hospitals are performing such procedures with outcomes equivalent to any U.S. center, with adverse event rates comparable or even substantially lower than at U.S. hospitals, and at markedly reduced costs.

Mr. Woodward estimates Americans traveling for health care can expect to save between 15% and 85% on the cost of equivalent care in the United States. Savings vary widely with the type of procedure, the country visited, and any add-ons such as vacation time. But for most major procedures the savings are massive.

Brazil, Costa Rica, and South Africa currently are hot destinations for cosmetic procedures; Costa Rica, Mexico, and Hungary are magnets for good, affordable dentistry; and India, Thailand, Malaysia, and Singapore are the best choices for major surgeries, including heart surgeries, organ transplants, and orthopedics, according to Mr. Woodward's book.

Friendly Physicians, Fine Food, and Feng Shui

Cost savings are a primary driver, but it is more than simple economics that attract Americans abroad. The leading international clinics can provide levels of service and comfort almost unheard of in U.S. hospitals.

Doctors in Asia or Latin America spend up to an hour per consultation, and routinely offer their personal cell phone numbers to patients and their families. Concierge services, four-star meal plans, and hotel-style accommodations are the rule, and travel packages often include limousine transport to and from the airport and clinic. The generally slower pace and the traditions of hospitality found overseas also may appeal to Americans shell-shocked by the frazzling pace and impersonal nature of U.S. health care.

Before 1997, the U.S. and Europe were the major recipients of international medical travelers, while Singapore was the major hub for Asia, explained Bumrungrad's Mr. Schroeder. In 1997, the economic crises in many Asian countries made price of care much more of an issue, so more Asians began to travel beyond their home borders for care.

After the attacks of Sept. 11, 2001, an increasing number of patients from the Middle East began traveling to Asia for care. “They used to go to America or Europe, but visas became problematic, so they started going to Thailand, Singapore, and India,” said Mr. Schroeder. He estimated Bumrungrad served 92,000 people from Middle Eastern countries in the last year; representing about 20% of total international business for the hospital.

In response to the influx of investment capital and international patient volume, hospitals in Thailand, India, and Singapore quickly ramped up their services. They built new facilities, installed state-of-the-art technology, sent physicians abroad for training in advanced therapeutics, and recruited clinicians from abroad.

The Bugbear of Aftercare

Follow-up and recourse if there are complications are a major concern to all involved with medical travel, and it is the aspect of this trend that makes American doctors most nervous.

“It's a very legitimate concern,” agreed Mr. Schroeder.

“A lot of the referrals to our hospital do not come from doctors because the patients do not have doctors. They're either outside their home health care systems (i.e., they are uninsured) or they are abandoning their home health care systems. Whenever we can, we do coordinate electronically with our patients' home doctors. If there are complications, we fly patients back, at our own expense, to take care of the problem. We do hold ourselves accountable for complications.”

Medical Outsourcing

According to Mr. Schroeder, “health care costs are capsizing American businesses. They're starting to look at international health care as a form of outsourcing. The idea, while not yet widespread, is gaining traction.”

He noted that Bumrungrad recently signed a landmark deal with Blue Cross of South Carolina, for a program called, Companion Global Healthcare, which would provide an alternative for people wishing to seek overseas health care.

“It is essentially a pilot project. There's no commercial insurance product attached to it yet. We're exploring processes. It's a learning situation. We're trying to feel it out and see if it can work,” said Mr. Schroeder.

The program provides subscribers with access to a specialized travel agency in Virginia that makes all arrangements for medical travel to Bumrungrad, and coordinates after-care through a network of South Carolina physicians.

But it is only a matter of time before U.S. insurers start actively driving patients overseas, predicted Jeffrey Lefko, a Chicago-based health care consultant who is working with Parkway Group Healthcare, a Singapore-based hospital system, to develop its U.S. referral base.

“It's not happening yet, but it is going to happen, and soon,” Mr. Lefko said in an interview. “A number of U.S. companies have started to work with self-insured plans to make procedures in Singapore a viable option. You're going to see much more of the insurance industry get interested in this.”

Further growth of medical travel, especially if pushed from the home front by U.S. insurers, could have major impact on American health care systems, but Dr. Jason Chin Huat Yap, medical director of the Singapore Tourism Board, said that he believes a lot of the unease surrounding these trends is unwarranted.

“Singapore's share of the global health care economy is about $12.6 billion. The U.S. share is about $2,000 billion. Even if you quadrupled our capacity and you threw in India, too, we're not even able to come close to providing health care for all Americans. It's still a very small fraction. There are massive supply-side constraints. If 1% of all U.S. patients came over to Singapore, it would outstrip our capacity. It's really only the first-movers who are going to benefit from this,” he said at the World Health Care Congress.

He added that a little bit of healthy competition from abroad, “could have a potentially positive structural impact on how the U.S. delivers health care services.”

Mr. Lefko said that he believes the emergence of world-class health care systems across the Pacific will likely give U.S. hospitals a much-needed kick in the bedpan.

“Already 500,000 Americans each year are leaving the U.S. for health care reasons, and this is going to grow. U.S. hospitals and doctors will complain, but the reality is U.S. hospitals have had plenty of time to straighten out their acts. They've had plenty of opportunities to create better, more economical health care services. Medical tourism's going to level the playing field. I've been in the hospital business for 35 years, and I've seen all sorts of facilities and operations. I wouldn't hesitate to go to any of the hospitals in Singapore,” Mr. Lefko said.

WASHINGTON — The emergence of medical centers in Asia, Latin America, and Eastern Europe that provide state-of-the-art procedures with a human touch and a gentle price tag has many U.S. citizens flying abroad to seek care they might have gotten at their local hospitals.

Medical travel—don't call it medical tourism anymore—has increased rapidly in recent years. In principle, there's nothing really new about it. For years, wealthy individuals from all over the world have flown to the United States or Western Europe for advanced procedures not available at home.

What is new is the ease of medical travel, the numbers of people getting treated away from home, and the direction: away from the United States and toward Asia, Eastern Europe, and Latin America.

Last year, roughly 150,000 Americans headed overseas for surgical procedures, estimated Josef Woodward, author of “Patients Without Borders: Everybody's Guide to Affordable, World-Class Medical Tourism” (Chapel Hill, N.C.: Healthy Travel Media, 2007), the first, but surely not the last, popular book on the subject. His estimate is conservative: Some observers put the number at closer to half a million.

Roughly 60,000 Americans have sought care at Bumrungrad International in Bangkok, widely recognized as one of Asia's leading hospitals, according to Curtis Schroeder, group CEO of Bumrungrad.

“Why travel to a hospital you can't even pronounce, in a country you've never visited, with doctors who have strange names you can't spell? There are several reasons: geopolitical factors; economic crises; lack of access to care, which is especially true for uninsured Americans or people from Western Europe who do not want to wait for services provided through their national health care systems; perceived lack of quality of care in their home countries; and family microeconomics,” said Mr. Schroeder, who previously was with Tenet Healthcare Systems, opening Tenet hospitals in several different countries.

Health care abroad is an appealing option for moderate-income Americans who are not insured. But even those with insurance are feeling the pinch and looking overseas. Mr. Schroeder cited a Time magazine survey indicating that 61% of uninsured Americans polled would travel 10,000 miles if they knew they could save $5,000 on a major medical procedure. Among those with insurance, the number was 40%.

“These are the first wave of medical tourists,” he said.

U.S. Standards … Better

According to Ori Karev, head of UnitedHealthGroup's Ovations program to improve health in people over age 50 years, there are 110 hospitals around the world accredited by the Joint Commission International that provide as good if not better quality health care than do top U.S. hospitals. JCI uses the same criteria as the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), and serves the same general purpose.

The International Organisation for Standardization, a 157-nation network of accrediting institutions based in Geneva, also accredits hospitals and clinics abroad, but focuses mainly on facilities management and administration, not clinical measures. “While ISO accreditation is good to see, it is of limited value in terms of treatment,” according to Mr. Woodward's book.

JCI-accredited hospitals, many of which are run as joint government-private sector partnerships, are typically founded on the relatively solid economic bedrock of national single-payer health systems. They provide services at far lower cost than U.S. hospitals in part because the surrounding social and cultural milieu is relatively free from many of the cost drivers in the U.S. system: insurance bureaucracy, tort law, high malpractice settlements, entitlement mentality, and deficit-spending lifestyles.

Once largely confined to elective cosmetic procedures or experimental treatments, medical travel now encompasses everything one would expect at an American or European tertiary-care center, including cardiovascular surgery, organ transplants, hip and knee replacements, and advanced cancer therapies. American- or European-trained clinicians at JCI-accredited hospitals are performing such procedures with outcomes equivalent to any U.S. center, with adverse event rates comparable or even substantially lower than at U.S. hospitals, and at markedly reduced costs.

Mr. Woodward estimates Americans traveling for health care can expect to save between 15% and 85% on the cost of equivalent care in the United States. Savings vary widely with the type of procedure, the country visited, and any add-ons such as vacation time. But for most major procedures the savings are massive.

Brazil, Costa Rica, and South Africa currently are hot destinations for cosmetic procedures; Costa Rica, Mexico, and Hungary are magnets for good, affordable dentistry; and India, Thailand, Malaysia, and Singapore are the best choices for major surgeries, including heart surgeries, organ transplants, and orthopedics, according to Mr. Woodward's book.

Friendly Physicians, Fine Food, and Feng Shui

Cost savings are a primary driver, but it is more than simple economics that attract Americans abroad. The leading international clinics can provide levels of service and comfort almost unheard of in U.S. hospitals.

Doctors in Asia or Latin America spend up to an hour per consultation, and routinely offer their personal cell phone numbers to patients and their families. Concierge services, four-star meal plans, and hotel-style accommodations are the rule, and travel packages often include limousine transport to and from the airport and clinic. The generally slower pace and the traditions of hospitality found overseas also may appeal to Americans shell-shocked by the frazzling pace and impersonal nature of U.S. health care.

Before 1997, the U.S. and Europe were the major recipients of international medical travelers, while Singapore was the major hub for Asia, explained Bumrungrad's Mr. Schroeder. In 1997, the economic crises in many Asian countries made price of care much more of an issue, so more Asians began to travel beyond their home borders for care.

After the attacks of Sept. 11, 2001, an increasing number of patients from the Middle East began traveling to Asia for care. “They used to go to America or Europe, but visas became problematic, so they started going to Thailand, Singapore, and India,” said Mr. Schroeder. He estimated Bumrungrad served 92,000 people from Middle Eastern countries in the last year; representing about 20% of total international business for the hospital.

In response to the influx of investment capital and international patient volume, hospitals in Thailand, India, and Singapore quickly ramped up their services. They built new facilities, installed state-of-the-art technology, sent physicians abroad for training in advanced therapeutics, and recruited clinicians from abroad.

The Bugbear of Aftercare

Follow-up and recourse if there are complications are a major concern to all involved with medical travel, and it is the aspect of this trend that makes American doctors most nervous.

“It's a very legitimate concern,” agreed Mr. Schroeder.

“A lot of the referrals to our hospital do not come from doctors because the patients do not have doctors. They're either outside their home health care systems (i.e., they are uninsured) or they are abandoning their home health care systems. Whenever we can, we do coordinate electronically with our patients' home doctors. If there are complications, we fly patients back, at our own expense, to take care of the problem. We do hold ourselves accountable for complications.”

Medical Outsourcing

According to Mr. Schroeder, “health care costs are capsizing American businesses. They're starting to look at international health care as a form of outsourcing. The idea, while not yet widespread, is gaining traction.”

He noted that Bumrungrad recently signed a landmark deal with Blue Cross of South Carolina, for a program called, Companion Global Healthcare, which would provide an alternative for people wishing to seek overseas health care.

“It is essentially a pilot project. There's no commercial insurance product attached to it yet. We're exploring processes. It's a learning situation. We're trying to feel it out and see if it can work,” said Mr. Schroeder.

The program provides subscribers with access to a specialized travel agency in Virginia that makes all arrangements for medical travel to Bumrungrad, and coordinates after-care through a network of South Carolina physicians.

But it is only a matter of time before U.S. insurers start actively driving patients overseas, predicted Jeffrey Lefko, a Chicago-based health care consultant who is working with Parkway Group Healthcare, a Singapore-based hospital system, to develop its U.S. referral base.

“It's not happening yet, but it is going to happen, and soon,” Mr. Lefko said in an interview. “A number of U.S. companies have started to work with self-insured plans to make procedures in Singapore a viable option. You're going to see much more of the insurance industry get interested in this.”

Further growth of medical travel, especially if pushed from the home front by U.S. insurers, could have major impact on American health care systems, but Dr. Jason Chin Huat Yap, medical director of the Singapore Tourism Board, said that he believes a lot of the unease surrounding these trends is unwarranted.

“Singapore's share of the global health care economy is about $12.6 billion. The U.S. share is about $2,000 billion. Even if you quadrupled our capacity and you threw in India, too, we're not even able to come close to providing health care for all Americans. It's still a very small fraction. There are massive supply-side constraints. If 1% of all U.S. patients came over to Singapore, it would outstrip our capacity. It's really only the first-movers who are going to benefit from this,” he said at the World Health Care Congress.

He added that a little bit of healthy competition from abroad, “could have a potentially positive structural impact on how the U.S. delivers health care services.”

Mr. Lefko said that he believes the emergence of world-class health care systems across the Pacific will likely give U.S. hospitals a much-needed kick in the bedpan.

“Already 500,000 Americans each year are leaving the U.S. for health care reasons, and this is going to grow. U.S. hospitals and doctors will complain, but the reality is U.S. hospitals have had plenty of time to straighten out their acts. They've had plenty of opportunities to create better, more economical health care services. Medical tourism's going to level the playing field. I've been in the hospital business for 35 years, and I've seen all sorts of facilities and operations. I wouldn't hesitate to go to any of the hospitals in Singapore,” Mr. Lefko said.

WASHINGTON — The globalization of health care is creating challenges for health care systems worldwide. Though the systems themselves may be very different in terms of financing and administration, the problems they must address—aging populations, increasing chronic disease, shrinking budgets, extreme mobility of both patients and health care professionals—are very similar.

Health care analysts, administrators, and providers compared notes on these challenges at the fourth annual World Health Care Congress, sponsored by the Wall Street Journal and CNBC.

“Despite the fact that health care may be organized and financed very differently in different countries, and there may be cultural differences, there are … a lot of common themes, and shared objectives for high-performing health care systems, innovation, and sustainability,” said Robin Osborn, director of the International Program in Health Policy and Practice at the Commonwealth Fund.

Simon Stevens, who served as a health care advisor in U.K. Prime Minister Tony Blair's cabinet, said the United States is not alone in confronting a major health care crisis. Single-payer national health systems of the sort found in the United Kingdom and all over Europe make the dynamics a bit different, but they certainly do not avert the crises.

“Despite differences in financing mechanisms, the challenges are similar across all industrialized nations. Tobacco, bad diet, lack of exercise are driving the conditions that result in the greatest consumption of health care resources, and tensions are erupting across [health care] systems due to changes in financing. The U.S. is not the only country debating these issues. The challenges are the same regardless of how you choose to finance the health care,” said Mr. Stevens, now the CEO of UnitedHealth Group's Ovations, a health plan for individuals over age 50.

Aging populations are the juggernauts straining health care systems in nearly all industrialized countries. Over the next 30 years, the dependency ratio, an expression of the number of elderly nonworking dependents versus younger working people, “will grow rapidly in the U.S., Western Europe, Japan, and China. And this will radically change how health care is financed,” Mr. Stevens said.

He added that while American corporate leaders have been screaming the loudest, the issues around employer-funded health care are not uniquely American.

In a number of European countries, corporations are footing the bill for significant chunks of health care spending. “In the U.K., 52% of spending is private sector spending, despite the fact that the delivery systems are government funded.”

Across the globe, health care is increasingly a transnational endeavor, with immigration, relocation, medical travel, and multinational business blurring borders. The establishment of the European Economic Community, the paragon of economic boundary breaking, has created an interesting health care quandary, said Mr. Stevens.

“In the earlier days of the [European Union], many had hopes that the confederation would lead to harmonization of health care benefits. Not so. Per capita spending on health care in Eastern and Western Europe is fourfold different. Western Europe spends way more. It is implausible to have a set of uniform benefits that are acceptable in Germany but unaffordable in Slovakia.”

Migration also has an impact. Whether for employment opportunity or in pursuit of leisure, more people are living outside their countries of origin, and this makes for some peculiar health care dilemmas.

Mr. Stevens noted that in many parts of the world, national borders are blurred. “In California, for example, we know there are 8 million Hispanics living in border counties. Many have dependents across the border in Mexico. How do we handle that? Can we mandate that dependents of U.S. employees only be treated in clinics in Mexico?”

At the other end of the socioeconomic spectrum, there are thousands of retired U.S. citizens living in Mexico, Costa Rica, Panama, and other Central American countries. They're eligible for Medicare, but unable to get coverage for medical services or drugs they obtain where they live. “Does this mean these people must fly back to the U.S. every time they need medical care?”

Physicians, nurses, and other medical personnel also have become highly mobile, often moving far from their countries of origin to countries of perceived opportunity. Citing only one example, Mr. Stevens said there are more Filipino nurses, born and trained in the Philippines, working in the United States than there are in the Philippines. In the European Union, there are significant migratory flows of health care professionals from east to west.

This can result in shortages of qualified professionals in many countries, hindering the growth and development of their medical systems.

Ironically, it is the influx of international patients seeking lower-cost health care that will be an important driver for the development of hospitals and the retaining of health professionals in nations such as Thailand, India, Hungary, and many Latin American countries.

Health plan administrators are struggling to figure out ways to do business without borders. The challenges are daunting, said UnitedHealth Group's Ori Karev.

Speaking specifically of coverage for Americans obtaining care outside the United States, he noted, “There are a lot of complicated issues involved in this: transportation issues, authorization issues, tax issues in terms of the ways in which the IRS will treat medical travel expenses.”

As countries such as India, Thailand, China, Brazil, and others become more affluent, their health care spending will increase, as will the number of risk-sharing plans.

WASHINGTON — The globalization of health care is creating challenges for health care systems worldwide. Though the systems themselves may be very different in terms of financing and administration, the problems they must address—aging populations, increasing chronic disease, shrinking budgets, extreme mobility of both patients and health care professionals—are very similar.

Health care analysts, administrators, and providers compared notes on these challenges at the fourth annual World Health Care Congress, sponsored by the Wall Street Journal and CNBC.

“Despite the fact that health care may be organized and financed very differently in different countries, and there may be cultural differences, there are … a lot of common themes, and shared objectives for high-performing health care systems, innovation, and sustainability,” said Robin Osborn, director of the International Program in Health Policy and Practice at the Commonwealth Fund.

Simon Stevens, who served as a health care advisor in U.K. Prime Minister Tony Blair's cabinet, said the United States is not alone in confronting a major health care crisis. Single-payer national health systems of the sort found in the United Kingdom and all over Europe make the dynamics a bit different, but they certainly do not avert the crises.

“Despite differences in financing mechanisms, the challenges are similar across all industrialized nations. Tobacco, bad diet, lack of exercise are driving the conditions that result in the greatest consumption of health care resources, and tensions are erupting across [health care] systems due to changes in financing. The U.S. is not the only country debating these issues. The challenges are the same regardless of how you choose to finance the health care,” said Mr. Stevens, now the CEO of UnitedHealth Group's Ovations, a health plan for individuals over age 50.

Aging populations are the juggernauts straining health care systems in nearly all industrialized countries. Over the next 30 years, the dependency ratio, an expression of the number of elderly nonworking dependents versus younger working people, “will grow rapidly in the U.S., Western Europe, Japan, and China. And this will radically change how health care is financed,” Mr. Stevens said.

He added that while American corporate leaders have been screaming the loudest, the issues around employer-funded health care are not uniquely American.

In a number of European countries, corporations are footing the bill for significant chunks of health care spending. “In the U.K., 52% of spending is private sector spending, despite the fact that the delivery systems are government funded.”

Across the globe, health care is increasingly a transnational endeavor, with immigration, relocation, medical travel, and multinational business blurring borders. The establishment of the European Economic Community, the paragon of economic boundary breaking, has created an interesting health care quandary, said Mr. Stevens.

“In the earlier days of the [European Union], many had hopes that the confederation would lead to harmonization of health care benefits. Not so. Per capita spending on health care in Eastern and Western Europe is fourfold different. Western Europe spends way more. It is implausible to have a set of uniform benefits that are acceptable in Germany but unaffordable in Slovakia.”

Migration also has an impact. Whether for employment opportunity or in pursuit of leisure, more people are living outside their countries of origin, and this makes for some peculiar health care dilemmas.

Mr. Stevens noted that in many parts of the world, national borders are blurred. “In California, for example, we know there are 8 million Hispanics living in border counties. Many have dependents across the border in Mexico. How do we handle that? Can we mandate that dependents of U.S. employees only be treated in clinics in Mexico?”

At the other end of the socioeconomic spectrum, there are thousands of retired U.S. citizens living in Mexico, Costa Rica, Panama, and other Central American countries. They're eligible for Medicare, but unable to get coverage for medical services or drugs they obtain where they live. “Does this mean these people must fly back to the U.S. every time they need medical care?”

Physicians, nurses, and other medical personnel also have become highly mobile, often moving far from their countries of origin to countries of perceived opportunity. Citing only one example, Mr. Stevens said there are more Filipino nurses, born and trained in the Philippines, working in the United States than there are in the Philippines. In the European Union, there are significant migratory flows of health care professionals from east to west.

This can result in shortages of qualified professionals in many countries, hindering the growth and development of their medical systems.

Ironically, it is the influx of international patients seeking lower-cost health care that will be an important driver for the development of hospitals and the retaining of health professionals in nations such as Thailand, India, Hungary, and many Latin American countries.

Health plan administrators are struggling to figure out ways to do business without borders. The challenges are daunting, said UnitedHealth Group's Ori Karev.

Speaking specifically of coverage for Americans obtaining care outside the United States, he noted, “There are a lot of complicated issues involved in this: transportation issues, authorization issues, tax issues in terms of the ways in which the IRS will treat medical travel expenses.”

As countries such as India, Thailand, China, Brazil, and others become more affluent, their health care spending will increase, as will the number of risk-sharing plans.

WASHINGTON — The globalization of health care is creating challenges for health care systems worldwide. Though the systems themselves may be very different in terms of financing and administration, the problems they must address—aging populations, increasing chronic disease, shrinking budgets, extreme mobility of both patients and health care professionals—are very similar.

Health care analysts, administrators, and providers compared notes on these challenges at the fourth annual World Health Care Congress, sponsored by the Wall Street Journal and CNBC.

“Despite the fact that health care may be organized and financed very differently in different countries, and there may be cultural differences, there are … a lot of common themes, and shared objectives for high-performing health care systems, innovation, and sustainability,” said Robin Osborn, director of the International Program in Health Policy and Practice at the Commonwealth Fund.

Simon Stevens, who served as a health care advisor in U.K. Prime Minister Tony Blair's cabinet, said the United States is not alone in confronting a major health care crisis. Single-payer national health systems of the sort found in the United Kingdom and all over Europe make the dynamics a bit different, but they certainly do not avert the crises.

“Despite differences in financing mechanisms, the challenges are similar across all industrialized nations. Tobacco, bad diet, lack of exercise are driving the conditions that result in the greatest consumption of health care resources, and tensions are erupting across [health care] systems due to changes in financing. The U.S. is not the only country debating these issues. The challenges are the same regardless of how you choose to finance the health care,” said Mr. Stevens, now the CEO of UnitedHealth Group's Ovations, a health plan for individuals over age 50.

Aging populations are the juggernauts straining health care systems in nearly all industrialized countries. Over the next 30 years, the dependency ratio, an expression of the number of elderly nonworking dependents versus younger working people, “will grow rapidly in the U.S., Western Europe, Japan, and China. And this will radically change how health care is financed,” Mr. Stevens said.

He added that while American corporate leaders have been screaming the loudest, the issues around employer-funded health care are not uniquely American.

In a number of European countries, corporations are footing the bill for significant chunks of health care spending. “In the U.K., 52% of spending is private sector spending, despite the fact that the delivery systems are government funded.”

Across the globe, health care is increasingly a transnational endeavor, with immigration, relocation, medical travel, and multinational business blurring borders. The establishment of the European Economic Community, the paragon of economic boundary breaking, has created an interesting health care quandary, said Mr. Stevens.

“In the earlier days of the [European Union], many had hopes that the confederation would lead to harmonization of health care benefits. Not so. Per capita spending on health care in Eastern and Western Europe is fourfold different. Western Europe spends way more. It is implausible to have a set of uniform benefits that are acceptable in Germany but unaffordable in Slovakia.”

Migration also has an impact. Whether for employment opportunity or in pursuit of leisure, more people are living outside their countries of origin, and this makes for some peculiar health care dilemmas.

Mr. Stevens noted that in many parts of the world, national borders are blurred. “In California, for example, we know there are 8 million Hispanics living in border counties. Many have dependents across the border in Mexico. How do we handle that? Can we mandate that dependents of U.S. employees only be treated in clinics in Mexico?”

At the other end of the socioeconomic spectrum, there are thousands of retired U.S. citizens living in Mexico, Costa Rica, Panama, and other Central American countries. They're eligible for Medicare, but unable to get coverage for medical services or drugs they obtain where they live. “Does this mean these people must fly back to the U.S. every time they need medical care?”

Physicians, nurses, and other medical personnel also have become highly mobile, often moving far from their countries of origin to countries of perceived opportunity. Citing only one example, Mr. Stevens said there are more Filipino nurses, born and trained in the Philippines, working in the United States than there are in the Philippines. In the European Union, there are significant migratory flows of health care professionals from east to west.

This can result in shortages of qualified professionals in many countries, hindering the growth and development of their medical systems.

Ironically, it is the influx of international patients seeking lower-cost health care that will be an important driver for the development of hospitals and the retaining of health professionals in nations such as Thailand, India, Hungary, and many Latin American countries.

Health plan administrators are struggling to figure out ways to do business without borders. The challenges are daunting, said UnitedHealth Group's Ori Karev.

Speaking specifically of coverage for Americans obtaining care outside the United States, he noted, “There are a lot of complicated issues involved in this: transportation issues, authorization issues, tax issues in terms of the ways in which the IRS will treat medical travel expenses.”

As countries such as India, Thailand, China, Brazil, and others become more affluent, their health care spending will increase, as will the number of risk-sharing plans.