Erik Goldman

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,” Mr. Stevens commented.

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,” he added.

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?” asked Mr. Stevens.

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.

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

Speaking specifically of coverage for Americans who are obtaining care outside the United States, he observed, “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. UnitedHealth Group is already a major health insurance player in India, with an employer-funded plan now covering 300,000 members via a large provider network.

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,” Mr. Stevens commented.

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,” he added.

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?” asked Mr. Stevens.

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.

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

Speaking specifically of coverage for Americans who are obtaining care outside the United States, he observed, “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. UnitedHealth Group is already a major health insurance player in India, with an employer-funded plan now covering 300,000 members via a large provider network.

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,” Mr. Stevens commented.

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,” he added.

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?” asked Mr. Stevens.

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.

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

Speaking specifically of coverage for Americans who are obtaining care outside the United States, he observed, “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. UnitedHealth Group is already a major health insurance player in India, with an employer-funded plan now covering 300,000 members via a large provider network.

WASHINGTON — The emergence of Asian, Latin American, and Eastern Europan medical centers that provide state-of-the-art procedures with a gentle price tag has many U.S. citizens flying abroad to seek care they might have gotten at their local hospitals, experts reported at the World Health Care Congress.

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 (JCI) 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 (ISO), a 157-nation network of accrediting institutions based in Geneva, also accredits hospitals and clinics abroad but focuses 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, and 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, Mr. Woodward wrote in his book.

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, he wrote. Mr. Woodward reported that 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 to or even substantially lower than at U.S. hospitals, and at markedly reduced costs.

Mr. Woodward estimated 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 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 that are 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 the 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 has 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 major concerns to all involved with medical travel, and they are the aspects of this trend that make 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 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 a 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.

Mr. Lefko said that healthy competition from abroad “could have a potentially positive structural impact on how the U.S. delivers health care services.” He believes the emergence of world-class health care 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.

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,” 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 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 patient's home country refer the patient 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 Asian, Latin American, and Eastern Europan medical centers that provide state-of-the-art procedures with a gentle price tag has many U.S. citizens flying abroad to seek care they might have gotten at their local hospitals, experts reported at the World Health Care Congress.

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 (JCI) 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 (ISO), a 157-nation network of accrediting institutions based in Geneva, also accredits hospitals and clinics abroad but focuses 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, and 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, Mr. Woodward wrote in his book.

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, he wrote. Mr. Woodward reported that 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 to or even substantially lower than at U.S. hospitals, and at markedly reduced costs.

Mr. Woodward estimated 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 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 that are 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 the 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 has 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 major concerns to all involved with medical travel, and they are the aspects of this trend that make 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 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 a 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.

Mr. Lefko said that healthy competition from abroad “could have a potentially positive structural impact on how the U.S. delivers health care services.” He believes the emergence of world-class health care 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.

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,” 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 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 patient's home country refer the patient 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 Asian, Latin American, and Eastern Europan medical centers that provide state-of-the-art procedures with a gentle price tag has many U.S. citizens flying abroad to seek care they might have gotten at their local hospitals, experts reported at the World Health Care Congress.

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 (JCI) 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 (ISO), a 157-nation network of accrediting institutions based in Geneva, also accredits hospitals and clinics abroad but focuses 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, and 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, Mr. Woodward wrote in his book.

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, he wrote. Mr. Woodward reported that 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 to or even substantially lower than at U.S. hospitals, and at markedly reduced costs.

Mr. Woodward estimated 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 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 that are 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 the 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 has 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 major concerns to all involved with medical travel, and they are the aspects of this trend that make 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 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 a 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.

Mr. Lefko said that healthy competition from abroad “could have a potentially positive structural impact on how the U.S. delivers health care services.” He believes the emergence of world-class health care 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.

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,” 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 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 patient's home country refer the patient 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 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 several 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.”

Around 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 has created an interesting health care quandary, Mr. Stevens said.

In the earlier days of the EU, many hoped that the confederation would lead to harmonization of health care benefits, but that has not happened. “Per capita spending on health care in Eastern and Western Europe is fourfold different,” he said. “Western Europe spends way more.”

Migration also has an impact. 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 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. 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 EU, 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 countries 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. Referring to coverage for Americans obtaining care outside the United States, he said there are many complicated issues involved, including those around transportation, authorization, and taxes– 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. UnitedHealth Group is already a major health insurance player in India, with an employer-funded plan now covering 300,000 members via a large provider network.

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 several 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.”

Around 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 has created an interesting health care quandary, Mr. Stevens said.

In the earlier days of the EU, many hoped that the confederation would lead to harmonization of health care benefits, but that has not happened. “Per capita spending on health care in Eastern and Western Europe is fourfold different,” he said. “Western Europe spends way more.”

Migration also has an impact. 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 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. 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 EU, 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 countries 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. Referring to coverage for Americans obtaining care outside the United States, he said there are many complicated issues involved, including those around transportation, authorization, and taxes– 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. UnitedHealth Group is already a major health insurance player in India, with an employer-funded plan now covering 300,000 members via a large provider network.

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 several 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.”

Around 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 has created an interesting health care quandary, Mr. Stevens said.

In the earlier days of the EU, many hoped that the confederation would lead to harmonization of health care benefits, but that has not happened. “Per capita spending on health care in Eastern and Western Europe is fourfold different,” he said. “Western Europe spends way more.”

Migration also has an impact. 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 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. 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 EU, 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 countries 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. Referring to coverage for Americans obtaining care outside the United States, he said there are many complicated issues involved, including those around transportation, authorization, and taxes– 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. UnitedHealth Group is already a major health insurance player in India, with an employer-funded plan now covering 300,000 members via a large provider network.

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 any more—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.

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, Feng Shui

Cost savings are a primary driver, but it is more than simple economics that attracts 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 physicians in South Carolina.

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," he said. "It's still a very small fraction."

Case in Point: 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," 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 patient 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 any more—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.

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, Feng Shui

Cost savings are a primary driver, but it is more than simple economics that attracts 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 physicians in South Carolina.

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," he said. "It's still a very small fraction."

Case in Point: 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," 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 patient 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 any more—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.

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, Feng Shui

Cost savings are a primary driver, but it is more than simple economics that attracts 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 physicians in South Carolina.

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," he said. "It's still a very small fraction."

Case in Point: 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," 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 patient 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."

PHILADELPHIA — Long-term antibiotic therapy for patients with acne induces complex immunologic and microbial changes that can have surprising clinical consequences not only for the patients but also for their close contacts, Whitney P. Bowe reported at the annual meeting of the Society for Investigative Dermatology.

For the last few years, researchers at the University of Pennsylvania, under the direction of Dr. David Margolis, have been exploring the microbial ecology of acne patients and the ways in which it is affected by antibiotic treatment.

They have discovered several phenomena. For one, acne patients on antibiotics are twice as likely to develop upper respiratory tract infections (URIs) than are those not treated. They are also three times more likely to carry group A streptococci in the oropharynx.

Some investigators have suggested that close contacts of antibiotic-treated acne patients may also be at increased risk for infectious conditions. Dr. Margolis' team recently completed a study that examined this conjecture. Ms. Bowe, a medical student and member of Dr. Margolis' research team, presented the findings in a poster.

The team analyzed data from the General Practice Research Database, which is an ongoing United Kingdom registry, and they determined rates of URIs among household contacts of acne patients.

They obtained data on 81,480 contacts of acne patients without URIs and 16,614 contacts of patients who did have URIs. The two cohorts were nearly equivalent in terms of their age (mean of 37 years) and sex (about 50% male).

Not surprisingly, the contacts of acne patients with URIs were more likely to have URIs themselves. Just over 6% of those in contact with a URI-affected acne patient also had a URI, compared with only 4% among the contacts of URI-free patients. Though the absolute numbers were small, the difference was statistically significant. The adjusted odds ratio for URI was 1.44 for close contacts of individuals with acne and URIs, meaning that close contacts of individuals with acne and URIs have a 44% increased risk of having a URI themselves.

The important question, said Ms. Bowe, is whether antibiotic therapy had any influence on this. “Some researchers have postulated that antibiotic exposure of any individual may affect the infectious illnesses of everyone in a group. One of our goals was to determine which factor plays more of a role in predicting URI in a household contact: exposure to an acne patient with a symptomatic URI or exposure to an acne patient on antibiotics.”

The answer proved clearly to be the former. The odds ratio for having a URI was 0.94 in household contacts of antibiotic-treated acne patients who did not have a URI and 0.71 in contacts of acne patients who had URIs and took antibiotics.

Contrary to some researchers' expectations, frequent exposure to an antibiotic-using acne patient seems to lower rather than raise the risk of URI among household contacts.

Whereas ongoing antibiotic therapy appears to increase the chances that an acne patient will develop a URI, the development of similar infections in household contacts is most likely owing to direct transmission of the pathogen and not to any increased susceptibility related to the patient's antibiotic use, as some have hypothesized.

“Although acne patients on antibiotics are about two times more likely to develop URIs, they appear to be less likely to transmit these URIs to their household contacts,” commented Ms. Bowe. “While this is reassuring from a public health perspective, the finding likely supports the hypothesis that acne antibiotics are immunomodulatory, predisposing acne patients to infections from pathogens that are not virulent enough to cause infection in fully immunocompetent hosts.”

PHILADELPHIA — Long-term antibiotic therapy for patients with acne induces complex immunologic and microbial changes that can have surprising clinical consequences not only for the patients but also for their close contacts, Whitney P. Bowe reported at the annual meeting of the Society for Investigative Dermatology.

For the last few years, researchers at the University of Pennsylvania, under the direction of Dr. David Margolis, have been exploring the microbial ecology of acne patients and the ways in which it is affected by antibiotic treatment.

They have discovered several phenomena. For one, acne patients on antibiotics are twice as likely to develop upper respiratory tract infections (URIs) than are those not treated. They are also three times more likely to carry group A streptococci in the oropharynx.

Some investigators have suggested that close contacts of antibiotic-treated acne patients may also be at increased risk for infectious conditions. Dr. Margolis' team recently completed a study that examined this conjecture. Ms. Bowe, a medical student and member of Dr. Margolis' research team, presented the findings in a poster.

The team analyzed data from the General Practice Research Database, which is an ongoing United Kingdom registry, and they determined rates of URIs among household contacts of acne patients.

They obtained data on 81,480 contacts of acne patients without URIs and 16,614 contacts of patients who did have URIs. The two cohorts were nearly equivalent in terms of their age (mean of 37 years) and sex (about 50% male).

Not surprisingly, the contacts of acne patients with URIs were more likely to have URIs themselves. Just over 6% of those in contact with a URI-affected acne patient also had a URI, compared with only 4% among the contacts of URI-free patients. Though the absolute numbers were small, the difference was statistically significant. The adjusted odds ratio for URI was 1.44 for close contacts of individuals with acne and URIs, meaning that close contacts of individuals with acne and URIs have a 44% increased risk of having a URI themselves.

The important question, said Ms. Bowe, is whether antibiotic therapy had any influence on this. “Some researchers have postulated that antibiotic exposure of any individual may affect the infectious illnesses of everyone in a group. One of our goals was to determine which factor plays more of a role in predicting URI in a household contact: exposure to an acne patient with a symptomatic URI or exposure to an acne patient on antibiotics.”

The answer proved clearly to be the former. The odds ratio for having a URI was 0.94 in household contacts of antibiotic-treated acne patients who did not have a URI and 0.71 in contacts of acne patients who had URIs and took antibiotics.

Contrary to some researchers' expectations, frequent exposure to an antibiotic-using acne patient seems to lower rather than raise the risk of URI among household contacts.

Whereas ongoing antibiotic therapy appears to increase the chances that an acne patient will develop a URI, the development of similar infections in household contacts is most likely owing to direct transmission of the pathogen and not to any increased susceptibility related to the patient's antibiotic use, as some have hypothesized.

“Although acne patients on antibiotics are about two times more likely to develop URIs, they appear to be less likely to transmit these URIs to their household contacts,” commented Ms. Bowe. “While this is reassuring from a public health perspective, the finding likely supports the hypothesis that acne antibiotics are immunomodulatory, predisposing acne patients to infections from pathogens that are not virulent enough to cause infection in fully immunocompetent hosts.”

PHILADELPHIA — Long-term antibiotic therapy for patients with acne induces complex immunologic and microbial changes that can have surprising clinical consequences not only for the patients but also for their close contacts, Whitney P. Bowe reported at the annual meeting of the Society for Investigative Dermatology.

For the last few years, researchers at the University of Pennsylvania, under the direction of Dr. David Margolis, have been exploring the microbial ecology of acne patients and the ways in which it is affected by antibiotic treatment.

They have discovered several phenomena. For one, acne patients on antibiotics are twice as likely to develop upper respiratory tract infections (URIs) than are those not treated. They are also three times more likely to carry group A streptococci in the oropharynx.

Some investigators have suggested that close contacts of antibiotic-treated acne patients may also be at increased risk for infectious conditions. Dr. Margolis' team recently completed a study that examined this conjecture. Ms. Bowe, a medical student and member of Dr. Margolis' research team, presented the findings in a poster.

The team analyzed data from the General Practice Research Database, which is an ongoing United Kingdom registry, and they determined rates of URIs among household contacts of acne patients.

They obtained data on 81,480 contacts of acne patients without URIs and 16,614 contacts of patients who did have URIs. The two cohorts were nearly equivalent in terms of their age (mean of 37 years) and sex (about 50% male).

Not surprisingly, the contacts of acne patients with URIs were more likely to have URIs themselves. Just over 6% of those in contact with a URI-affected acne patient also had a URI, compared with only 4% among the contacts of URI-free patients. Though the absolute numbers were small, the difference was statistically significant. The adjusted odds ratio for URI was 1.44 for close contacts of individuals with acne and URIs, meaning that close contacts of individuals with acne and URIs have a 44% increased risk of having a URI themselves.

The important question, said Ms. Bowe, is whether antibiotic therapy had any influence on this. “Some researchers have postulated that antibiotic exposure of any individual may affect the infectious illnesses of everyone in a group. One of our goals was to determine which factor plays more of a role in predicting URI in a household contact: exposure to an acne patient with a symptomatic URI or exposure to an acne patient on antibiotics.”

The answer proved clearly to be the former. The odds ratio for having a URI was 0.94 in household contacts of antibiotic-treated acne patients who did not have a URI and 0.71 in contacts of acne patients who had URIs and took antibiotics.

Contrary to some researchers' expectations, frequent exposure to an antibiotic-using acne patient seems to lower rather than raise the risk of URI among household contacts.

Whereas ongoing antibiotic therapy appears to increase the chances that an acne patient will develop a URI, the development of similar infections in household contacts is most likely owing to direct transmission of the pathogen and not to any increased susceptibility related to the patient's antibiotic use, as some have hypothesized.

“Although acne patients on antibiotics are about two times more likely to develop URIs, they appear to be less likely to transmit these URIs to their household contacts,” commented Ms. Bowe. “While this is reassuring from a public health perspective, the finding likely supports the hypothesis that acne antibiotics are immunomodulatory, predisposing acne patients to infections from pathogens that are not virulent enough to cause infection in fully immunocompetent hosts.”

MADRID — Fasting blood glucose levels appear to be higher in diabetic patients with poorly controlled blood pressure than in those with well-controlled pressure, said Dr. Miroslav Soucek, at the annual meeting of the European Society of Hypertension.

This observation was based on a survey of more than 2,200 patients from 150 primary care practices in the Czech Republic. The primary objective of the study was to determine the prevalence of hypertension in the Czech population and the extent to which physicians can help their patients achieve pressure control targets as outlined in current ESH guidelines, said Dr. Soucek, who presented the findings in a poster.

Each participating physician recorded thorough case data from 15 consecutive patients aged at least 45 years, irrespective of the reason for each patient's visit, to get a representative sampling of the health status of all those who visited primary care offices. The investigators defined hypertension as pressures above 140/90 mm Hg.

Dr. Soucek and his colleagues obtained data from 2,211 patients with a mean age of 62 years. Of the entire cohort, 78% of the patients were defined as hypertensive; of the 403 patients with diabetes, 75% had hypertension. Only 18% of patients being treated for hypertension were considered well controlled (pressures under 130/80 mm Hg); the rate for diabetics was 6%. He noted that blood pressure was uncontrolled in almost 30% of the diabetic patients with hypertension even though they were on at least three antihypertensive drugs.

But the most striking finding was the correlation between poor pressure control and increased fasting blood glucose.

“The average fasting blood glucose showed a gradual increase, with increasing blood pressure, from 7.98 mmol/L in diabetics with blood pressure under 130/80 mm Hg to 9.44 in diabetic patients with blood pressures greater than 180/110 mm Hg,” reported Dr. Soucek of the department of internal medicine, St. Anne University Hospital, Brno, Czech Republic, adding that the mechanism underlying this connection is not known.

Uncontrolled pressure in a diabetic patient may signal uncontrolled glucose, and such patients need even closer attention than nondiabetic hypertensives or diabetics who are not hypertensive, he said.

ELSEVIER GLOBAL MEDICAL NEWS

MADRID — Fasting blood glucose levels appear to be higher in diabetic patients with poorly controlled blood pressure than in those with well-controlled pressure, said Dr. Miroslav Soucek, at the annual meeting of the European Society of Hypertension.

This observation was based on a survey of more than 2,200 patients from 150 primary care practices in the Czech Republic. The primary objective of the study was to determine the prevalence of hypertension in the Czech population and the extent to which physicians can help their patients achieve pressure control targets as outlined in current ESH guidelines, said Dr. Soucek, who presented the findings in a poster.

Each participating physician recorded thorough case data from 15 consecutive patients aged at least 45 years, irrespective of the reason for each patient's visit, to get a representative sampling of the health status of all those who visited primary care offices. The investigators defined hypertension as pressures above 140/90 mm Hg.

Dr. Soucek and his colleagues obtained data from 2,211 patients with a mean age of 62 years. Of the entire cohort, 78% of the patients were defined as hypertensive; of the 403 patients with diabetes, 75% had hypertension. Only 18% of patients being treated for hypertension were considered well controlled (pressures under 130/80 mm Hg); the rate for diabetics was 6%. He noted that blood pressure was uncontrolled in almost 30% of the diabetic patients with hypertension even though they were on at least three antihypertensive drugs.

But the most striking finding was the correlation between poor pressure control and increased fasting blood glucose.

“The average fasting blood glucose showed a gradual increase, with increasing blood pressure, from 7.98 mmol/L in diabetics with blood pressure under 130/80 mm Hg to 9.44 in diabetic patients with blood pressures greater than 180/110 mm Hg,” reported Dr. Soucek of the department of internal medicine, St. Anne University Hospital, Brno, Czech Republic, adding that the mechanism underlying this connection is not known.

Uncontrolled pressure in a diabetic patient may signal uncontrolled glucose, and such patients need even closer attention than nondiabetic hypertensives or diabetics who are not hypertensive, he said.

ELSEVIER GLOBAL MEDICAL NEWS

MADRID — Fasting blood glucose levels appear to be higher in diabetic patients with poorly controlled blood pressure than in those with well-controlled pressure, said Dr. Miroslav Soucek, at the annual meeting of the European Society of Hypertension.

This observation was based on a survey of more than 2,200 patients from 150 primary care practices in the Czech Republic. The primary objective of the study was to determine the prevalence of hypertension in the Czech population and the extent to which physicians can help their patients achieve pressure control targets as outlined in current ESH guidelines, said Dr. Soucek, who presented the findings in a poster.

Each participating physician recorded thorough case data from 15 consecutive patients aged at least 45 years, irrespective of the reason for each patient's visit, to get a representative sampling of the health status of all those who visited primary care offices. The investigators defined hypertension as pressures above 140/90 mm Hg.

Dr. Soucek and his colleagues obtained data from 2,211 patients with a mean age of 62 years. Of the entire cohort, 78% of the patients were defined as hypertensive; of the 403 patients with diabetes, 75% had hypertension. Only 18% of patients being treated for hypertension were considered well controlled (pressures under 130/80 mm Hg); the rate for diabetics was 6%. He noted that blood pressure was uncontrolled in almost 30% of the diabetic patients with hypertension even though they were on at least three antihypertensive drugs.

But the most striking finding was the correlation between poor pressure control and increased fasting blood glucose.

“The average fasting blood glucose showed a gradual increase, with increasing blood pressure, from 7.98 mmol/L in diabetics with blood pressure under 130/80 mm Hg to 9.44 in diabetic patients with blood pressures greater than 180/110 mm Hg,” reported Dr. Soucek of the department of internal medicine, St. Anne University Hospital, Brno, Czech Republic, adding that the mechanism underlying this connection is not known.

Uncontrolled pressure in a diabetic patient may signal uncontrolled glucose, and such patients need even closer attention than nondiabetic hypertensives or diabetics who are not hypertensive, he said.

ELSEVIER GLOBAL MEDICAL NEWS

MADRID — Aliskiren, the novel renin-blocking drug, improved 24-hour blood pressure control and showed greater systolic pressure reductions, compared with ramipril, in diabetics with uncontrolled hypertension, according to data presented at the annual meeting of the European Society of Hypertension.

Aliskiren also can be safely combined with the ACE inhibitor in this population, the combination giving the greatest degree of pressure. Aliskiren works by blocking the renin-regulated conversion of circulating angiotensinogen to angiotensin-1. The new drug, also known by the brand name Rasilez, is the first of what may soon be a burgeoning class of renin blockers. It is being considered for approval by regulatory authorities in Europe and the United States.

Dr. Yagiz Uresin, professor of clinical pharmacology at Istanbul (Turkey) University, presented a multicenter international study of 837 patients with diabetes and hypertension. At baseline, the patients had blood pressures of over 155 mm Hg systolic and 98 mm Hg diastolic.

After a washout period and a placebo run-in of 2–4 weeks, the patients were randomized to aliskiren monotherapy, 150 mg/day; ramipril monotherapy, 5 mg/day; or a combination of 150 mg aliskiren plus 5 mg ramipril per day. After 4 weeks, the investigators doubled the doses in all study groups.

After 8 weeks, aliskiren gave mean pressure reductions of 14.7 mm Hg systolic and 11.3 mm Hg diastolic. This was significantly better than the 12.0- and 10.7-mm Hg reductions with ramipril alone. In combination, the two drugs gave mean pressure reductions of 16.6 mm Hg systolic and 12.8 mm Hg diastolic.

With a target pressure of 130/80 mm Hg, slightly over 8% of the patients in the monotherapy arms could be considered well controlled by the end of the study. Combination therapy bumped this up to 13%. The low number of patients who were able to reach target pressures reflects the difficulty of treating longstanding hypertension in diabetic patients, said Dr. Uresin.

A separate subgroup analysis drawn from the same international cohort showed that aliskiren alone and in combination with ramipril gave significantly better round-the-clock diastolic pressure control than did ramipril alone.

A total of 173 patients, 55 on ramipril alone, 57 on aliskiren alone, and 61 on the combination, underwent 24-hour ambulatory monitoring. Using the smoothness index, a scale that measures the consistency of pressure control over a 24-hour period, the investigators found that aliskiren alone and in combination with ramipril provides significantly greater consistency over the course of a day. Smoothness index scores correlate with reversal of left ventricular hypertrophy and carotid artery wall thickening.

The difference between renin-blockade and ACE inhibition was greatest in the early morning hours. At 21–24 hours post dose, the renin blocker alone and in combination with ramipril gave significantly better pressure control than did ramipril alone. Systolic pressures remained between 4 and 12 mm Hg below baseline in patients on aliskiren or aliskiren plus ramipril. In the ramipril group, systolic pressure rose to near baseline levels at the end of the 24-hour dosing cycle.

Adverse effects in the new study were similar to those in earlier trials showing aliskiren as having a low side-effect profile. About one-third of the patients in each monotherapy group had some untoward effects, the most common being headache, cough, nasopharyngitis, and diarrhea. These were mild and self-limiting in the vast majority. Just over 2% of the ramipril monotherapy group and just under 3% of the aliskiren group had serious side effects; the incidence was reduced to 1.4% for the combination.

Adding aliskiren to ramipril can cut the incidence of coughing, the most common reason patients quit ACE inhibitor therapy. Dr. Uresin noted the incidence of cough was just under 5% in the ramipril-alone group, just over 2% for aliskiren, and 1.8% in those taking the combination. The difference was statistically significant. The mechanism underlying the cough attenuation may have to do with reduced bradykinin levels following renin blockade, he said.

MADRID — Aliskiren, the novel renin-blocking drug, improved 24-hour blood pressure control and showed greater systolic pressure reductions, compared with ramipril, in diabetics with uncontrolled hypertension, according to data presented at the annual meeting of the European Society of Hypertension.

Aliskiren also can be safely combined with the ACE inhibitor in this population, the combination giving the greatest degree of pressure. Aliskiren works by blocking the renin-regulated conversion of circulating angiotensinogen to angiotensin-1. The new drug, also known by the brand name Rasilez, is the first of what may soon be a burgeoning class of renin blockers. It is being considered for approval by regulatory authorities in Europe and the United States.

Dr. Yagiz Uresin, professor of clinical pharmacology at Istanbul (Turkey) University, presented a multicenter international study of 837 patients with diabetes and hypertension. At baseline, the patients had blood pressures of over 155 mm Hg systolic and 98 mm Hg diastolic.

After a washout period and a placebo run-in of 2–4 weeks, the patients were randomized to aliskiren monotherapy, 150 mg/day; ramipril monotherapy, 5 mg/day; or a combination of 150 mg aliskiren plus 5 mg ramipril per day. After 4 weeks, the investigators doubled the doses in all study groups.

After 8 weeks, aliskiren gave mean pressure reductions of 14.7 mm Hg systolic and 11.3 mm Hg diastolic. This was significantly better than the 12.0- and 10.7-mm Hg reductions with ramipril alone. In combination, the two drugs gave mean pressure reductions of 16.6 mm Hg systolic and 12.8 mm Hg diastolic.

With a target pressure of 130/80 mm Hg, slightly over 8% of the patients in the monotherapy arms could be considered well controlled by the end of the study. Combination therapy bumped this up to 13%. The low number of patients who were able to reach target pressures reflects the difficulty of treating longstanding hypertension in diabetic patients, said Dr. Uresin.

A separate subgroup analysis drawn from the same international cohort showed that aliskiren alone and in combination with ramipril gave significantly better round-the-clock diastolic pressure control than did ramipril alone.

A total of 173 patients, 55 on ramipril alone, 57 on aliskiren alone, and 61 on the combination, underwent 24-hour ambulatory monitoring. Using the smoothness index, a scale that measures the consistency of pressure control over a 24-hour period, the investigators found that aliskiren alone and in combination with ramipril provides significantly greater consistency over the course of a day. Smoothness index scores correlate with reversal of left ventricular hypertrophy and carotid artery wall thickening.

The difference between renin-blockade and ACE inhibition was greatest in the early morning hours. At 21–24 hours post dose, the renin blocker alone and in combination with ramipril gave significantly better pressure control than did ramipril alone. Systolic pressures remained between 4 and 12 mm Hg below baseline in patients on aliskiren or aliskiren plus ramipril. In the ramipril group, systolic pressure rose to near baseline levels at the end of the 24-hour dosing cycle.

Adverse effects in the new study were similar to those in earlier trials showing aliskiren as having a low side-effect profile. About one-third of the patients in each monotherapy group had some untoward effects, the most common being headache, cough, nasopharyngitis, and diarrhea. These were mild and self-limiting in the vast majority. Just over 2% of the ramipril monotherapy group and just under 3% of the aliskiren group had serious side effects; the incidence was reduced to 1.4% for the combination.

Adding aliskiren to ramipril can cut the incidence of coughing, the most common reason patients quit ACE inhibitor therapy. Dr. Uresin noted the incidence of cough was just under 5% in the ramipril-alone group, just over 2% for aliskiren, and 1.8% in those taking the combination. The difference was statistically significant. The mechanism underlying the cough attenuation may have to do with reduced bradykinin levels following renin blockade, he said.

MADRID — Aliskiren, the novel renin-blocking drug, improved 24-hour blood pressure control and showed greater systolic pressure reductions, compared with ramipril, in diabetics with uncontrolled hypertension, according to data presented at the annual meeting of the European Society of Hypertension.

Aliskiren also can be safely combined with the ACE inhibitor in this population, the combination giving the greatest degree of pressure. Aliskiren works by blocking the renin-regulated conversion of circulating angiotensinogen to angiotensin-1. The new drug, also known by the brand name Rasilez, is the first of what may soon be a burgeoning class of renin blockers. It is being considered for approval by regulatory authorities in Europe and the United States.

Dr. Yagiz Uresin, professor of clinical pharmacology at Istanbul (Turkey) University, presented a multicenter international study of 837 patients with diabetes and hypertension. At baseline, the patients had blood pressures of over 155 mm Hg systolic and 98 mm Hg diastolic.

After a washout period and a placebo run-in of 2–4 weeks, the patients were randomized to aliskiren monotherapy, 150 mg/day; ramipril monotherapy, 5 mg/day; or a combination of 150 mg aliskiren plus 5 mg ramipril per day. After 4 weeks, the investigators doubled the doses in all study groups.

After 8 weeks, aliskiren gave mean pressure reductions of 14.7 mm Hg systolic and 11.3 mm Hg diastolic. This was significantly better than the 12.0- and 10.7-mm Hg reductions with ramipril alone. In combination, the two drugs gave mean pressure reductions of 16.6 mm Hg systolic and 12.8 mm Hg diastolic.

With a target pressure of 130/80 mm Hg, slightly over 8% of the patients in the monotherapy arms could be considered well controlled by the end of the study. Combination therapy bumped this up to 13%. The low number of patients who were able to reach target pressures reflects the difficulty of treating longstanding hypertension in diabetic patients, said Dr. Uresin.

A separate subgroup analysis drawn from the same international cohort showed that aliskiren alone and in combination with ramipril gave significantly better round-the-clock diastolic pressure control than did ramipril alone.

A total of 173 patients, 55 on ramipril alone, 57 on aliskiren alone, and 61 on the combination, underwent 24-hour ambulatory monitoring. Using the smoothness index, a scale that measures the consistency of pressure control over a 24-hour period, the investigators found that aliskiren alone and in combination with ramipril provides significantly greater consistency over the course of a day. Smoothness index scores correlate with reversal of left ventricular hypertrophy and carotid artery wall thickening.

The difference between renin-blockade and ACE inhibition was greatest in the early morning hours. At 21–24 hours post dose, the renin blocker alone and in combination with ramipril gave significantly better pressure control than did ramipril alone. Systolic pressures remained between 4 and 12 mm Hg below baseline in patients on aliskiren or aliskiren plus ramipril. In the ramipril group, systolic pressure rose to near baseline levels at the end of the 24-hour dosing cycle.

Adverse effects in the new study were similar to those in earlier trials showing aliskiren as having a low side-effect profile. About one-third of the patients in each monotherapy group had some untoward effects, the most common being headache, cough, nasopharyngitis, and diarrhea. These were mild and self-limiting in the vast majority. Just over 2% of the ramipril monotherapy group and just under 3% of the aliskiren group had serious side effects; the incidence was reduced to 1.4% for the combination.

Adding aliskiren to ramipril can cut the incidence of coughing, the most common reason patients quit ACE inhibitor therapy. Dr. Uresin noted the incidence of cough was just under 5% in the ramipril-alone group, just over 2% for aliskiren, and 1.8% in those taking the combination. The difference was statistically significant. The mechanism underlying the cough attenuation may have to do with reduced bradykinin levels following renin blockade, he said.

MADRID — Antihypertensive therapy with candesartan was shown to reverse left ventricular hypertrophy in a study, Dr. Vivencio Barrios reported at the annual meeting of the European Society of Hypertension.

Findings in several recently published controlled randomized trials have shown that regression of electrocardiographic left ventricular hypertrophy (LVH) improves prognosis of hypertensive patients, “but information on LVH regression in clinical practice has been scarce,” said Dr. Barrios of the cardiology institute at Ramon y Cajal Hospital, Madrid.

Dr. Barrios was the lead investigator in an open-label, 12-month study evaluating the impact of candesartan, an angiotensin-1 receptor blocker, on LVH in a real-world practice setting. The study involved 276 patients with uncontrolled essential hypertension. The mean blood pressure at baseline was 164/92 mm Hg. The patients' average age was 62 years, and 18% had diabetes.

The researchers assessed LVH with electrocardiography by using the Cornell voltage duration product (VDP) measurement, as well as QRS-segment duration. The baseline and posttreatment ECG tracings were assessed by a single lab, by a blinded investigator. At the outset of the study, 24% of the patients had LVH.

Patients were treated with candesartan 8 mg/day or 16 mg/day, with the objective of reaching pressures below 140/90 mm Hg for nondiabetics or 130/80 for diabetic patients. The researchers could add other antihypertensive medications if the pressure values did not drop within target ranges after several months.

At 12 months, the angiotensin-1 receptor blocker produced the expected degree of pressure reduction, decreasing the baseline mean values of 164/92 mm Hg to 143/84 mm Hg. It also produced a significant decrease in the prevalence of LVH. By the end of the study, 20% of the study population had ECG evidence of LVH, down from 24% at the outset. Of those with LVH, 19% showed observable LVH regressions.

On average, the VDP was significantly reduced by 132.88 mm × msec; the QRS interval was also reduced by 2.95 msec, both indicating a trend away from LVH.

The VDP changes were larger in older patients and in those with higher baseline VDP values, suggesting candesartan offers the greatest potential benefit in those with the most advanced LVH.

Earlier detection and reversal of LVH is of great concern among hypertension specialists who hope that primary care physicians will join them in their efforts to prevent heart failure, for which advanced age and presence of LVH are the top risk factors.

MADRID — Antihypertensive therapy with candesartan was shown to reverse left ventricular hypertrophy in a study, Dr. Vivencio Barrios reported at the annual meeting of the European Society of Hypertension.

Findings in several recently published controlled randomized trials have shown that regression of electrocardiographic left ventricular hypertrophy (LVH) improves prognosis of hypertensive patients, “but information on LVH regression in clinical practice has been scarce,” said Dr. Barrios of the cardiology institute at Ramon y Cajal Hospital, Madrid.

Dr. Barrios was the lead investigator in an open-label, 12-month study evaluating the impact of candesartan, an angiotensin-1 receptor blocker, on LVH in a real-world practice setting. The study involved 276 patients with uncontrolled essential hypertension. The mean blood pressure at baseline was 164/92 mm Hg. The patients' average age was 62 years, and 18% had diabetes.

The researchers assessed LVH with electrocardiography by using the Cornell voltage duration product (VDP) measurement, as well as QRS-segment duration. The baseline and posttreatment ECG tracings were assessed by a single lab, by a blinded investigator. At the outset of the study, 24% of the patients had LVH.

Patients were treated with candesartan 8 mg/day or 16 mg/day, with the objective of reaching pressures below 140/90 mm Hg for nondiabetics or 130/80 for diabetic patients. The researchers could add other antihypertensive medications if the pressure values did not drop within target ranges after several months.

At 12 months, the angiotensin-1 receptor blocker produced the expected degree of pressure reduction, decreasing the baseline mean values of 164/92 mm Hg to 143/84 mm Hg. It also produced a significant decrease in the prevalence of LVH. By the end of the study, 20% of the study population had ECG evidence of LVH, down from 24% at the outset. Of those with LVH, 19% showed observable LVH regressions.

On average, the VDP was significantly reduced by 132.88 mm × msec; the QRS interval was also reduced by 2.95 msec, both indicating a trend away from LVH.

The VDP changes were larger in older patients and in those with higher baseline VDP values, suggesting candesartan offers the greatest potential benefit in those with the most advanced LVH.

Earlier detection and reversal of LVH is of great concern among hypertension specialists who hope that primary care physicians will join them in their efforts to prevent heart failure, for which advanced age and presence of LVH are the top risk factors.

MADRID — Antihypertensive therapy with candesartan was shown to reverse left ventricular hypertrophy in a study, Dr. Vivencio Barrios reported at the annual meeting of the European Society of Hypertension.

Findings in several recently published controlled randomized trials have shown that regression of electrocardiographic left ventricular hypertrophy (LVH) improves prognosis of hypertensive patients, “but information on LVH regression in clinical practice has been scarce,” said Dr. Barrios of the cardiology institute at Ramon y Cajal Hospital, Madrid.

Dr. Barrios was the lead investigator in an open-label, 12-month study evaluating the impact of candesartan, an angiotensin-1 receptor blocker, on LVH in a real-world practice setting. The study involved 276 patients with uncontrolled essential hypertension. The mean blood pressure at baseline was 164/92 mm Hg. The patients' average age was 62 years, and 18% had diabetes.

The researchers assessed LVH with electrocardiography by using the Cornell voltage duration product (VDP) measurement, as well as QRS-segment duration. The baseline and posttreatment ECG tracings were assessed by a single lab, by a blinded investigator. At the outset of the study, 24% of the patients had LVH.

Patients were treated with candesartan 8 mg/day or 16 mg/day, with the objective of reaching pressures below 140/90 mm Hg for nondiabetics or 130/80 for diabetic patients. The researchers could add other antihypertensive medications if the pressure values did not drop within target ranges after several months.

At 12 months, the angiotensin-1 receptor blocker produced the expected degree of pressure reduction, decreasing the baseline mean values of 164/92 mm Hg to 143/84 mm Hg. It also produced a significant decrease in the prevalence of LVH. By the end of the study, 20% of the study population had ECG evidence of LVH, down from 24% at the outset. Of those with LVH, 19% showed observable LVH regressions.

On average, the VDP was significantly reduced by 132.88 mm × msec; the QRS interval was also reduced by 2.95 msec, both indicating a trend away from LVH.

The VDP changes were larger in older patients and in those with higher baseline VDP values, suggesting candesartan offers the greatest potential benefit in those with the most advanced LVH.

Earlier detection and reversal of LVH is of great concern among hypertension specialists who hope that primary care physicians will join them in their efforts to prevent heart failure, for which advanced age and presence of LVH are the top risk factors.

MADRID — Melatonin supplementation can improve nocturnal blood pressure control and prevent early morning pressure surges in hypertensive patients who do not show the typical nighttime pressure drop, according to results presented at the annual meeting of the European Society of Hypertension.

But another dietary supplement—vitamin E—was shown to increase blood pressure in diabetic hypertensive patients in a second study reported at the meeting.

“Impaired nocturnal blood pressure fall is associated with increased risk of target organ damage related to hypertension,” said Dr. Yehonatan Sharabi of the Chaim Sheba Medical Center, Tel Hashomer, Israel, presenting the melatonin study.

It is not clear why some patients fail to show the usual nighttime pressure drop, but lack of melatonin, a hormone secreted by the pineal gland, may play a role. In patients with a blunted nocturnal blood pressure fall, the amount of urinary 6-sulfatoxymelatonin, the key metabolite of melatonin, is markedly reduced.

The Israeli team, with researchers at Gazi University, Ankara, Turkey, tested melatonin in 38 nonobese hypertensive patients already on one or more antihypertensive drugs. They were generally well controlled except for the impaired nighttime pressure fall and increased early morning pressure surges. Mean age was 64 years, with a range of 42–83 years. Those with insomnia were excluded.

After a 2-week placebo run-in period, the patients underwent baseline 24-hour ambulatory pressure monitoring, then were randomized to either 2 mg of controlled-release melatonin per day or placebo. They were instructed to take the assigned tablet 2 hours before bedtime. After 4 weeks, they underwent 24-hour monitoring. At baseline, the melatonin patients had mean morning pressures of 141/78 mm Hg and mean nighttime pressures of 136/72 mm Hg. The placebo group showed similar baseline values. There were no significant changes in daytime systolic pressure in response to melatonin. But nighttime pressures showed a mean drop of 7 mm Hg systolic and 3 mm Hg diastolic in the melatonin group. There was no such change in the placebo group.

“The time interval from 1 a.m. to 5 a.m. seemed to be the period of maximal melatonin effect on blood pressure, and this is very important, given the incidence of early morning cardiovascular events,” said Dr. Sharabi. No adverse effects were associated with melatonin, and compliance was high, he said.

In a separate study, vitamin E induced substantial increases in mean daytime and nighttime blood pressures in diabetic patients with hypertension, compared with those who were given a soy oil placebo, reported Dr. Ian B. Puddey of the department of medicine, University of Western Australia, Perth.

Although the supplements reduced oxidative stress, as indicated by consistent falls in urinary isoprostane (a marker of oxidative stress), this presumable benefit is nullified by the unexpected rise in systolic and diastolic pressures, as well as pulse pressure and pulse rate.

After a 3-week run-in period, 55 patients with type 2 diabetes and hypertension were randomized to placebo (soy oil stripped of all tocopherols), 500 mg/day of alpha-tocopherol, or 500 mg/day of mixed gamma-, alpha-, and delta-tocopherols. About half of the patients were on at least one antihypertensive drug; two-thirds were on lipid-lowering drugs.

“Contrary to our central hypothesis, we observed a small fall in blood pressure in the placebo group but increased mean pressures in both the alpha-tocopherol and mixed tocopherol groups,” said Dr. Puddey, who presented the data on behalf of the lead investigator, Dr. N.C. Ward. The mean increase was 7 mm Hg systolic and 5 mm Hg diastolic for the patients treated with vitamin E. The 24-hour ambulatory profile showed a sustained and consistent pressure increase throughout the day, with no diurnal variation.

MADRID — Melatonin supplementation can improve nocturnal blood pressure control and prevent early morning pressure surges in hypertensive patients who do not show the typical nighttime pressure drop, according to results presented at the annual meeting of the European Society of Hypertension.

But another dietary supplement—vitamin E—was shown to increase blood pressure in diabetic hypertensive patients in a second study reported at the meeting.

“Impaired nocturnal blood pressure fall is associated with increased risk of target organ damage related to hypertension,” said Dr. Yehonatan Sharabi of the Chaim Sheba Medical Center, Tel Hashomer, Israel, presenting the melatonin study.

It is not clear why some patients fail to show the usual nighttime pressure drop, but lack of melatonin, a hormone secreted by the pineal gland, may play a role. In patients with a blunted nocturnal blood pressure fall, the amount of urinary 6-sulfatoxymelatonin, the key metabolite of melatonin, is markedly reduced.

The Israeli team, with researchers at Gazi University, Ankara, Turkey, tested melatonin in 38 nonobese hypertensive patients already on one or more antihypertensive drugs. They were generally well controlled except for the impaired nighttime pressure fall and increased early morning pressure surges. Mean age was 64 years, with a range of 42–83 years. Those with insomnia were excluded.

After a 2-week placebo run-in period, the patients underwent baseline 24-hour ambulatory pressure monitoring, then were randomized to either 2 mg of controlled-release melatonin per day or placebo. They were instructed to take the assigned tablet 2 hours before bedtime. After 4 weeks, they underwent 24-hour monitoring. At baseline, the melatonin patients had mean morning pressures of 141/78 mm Hg and mean nighttime pressures of 136/72 mm Hg. The placebo group showed similar baseline values. There were no significant changes in daytime systolic pressure in response to melatonin. But nighttime pressures showed a mean drop of 7 mm Hg systolic and 3 mm Hg diastolic in the melatonin group. There was no such change in the placebo group.

“The time interval from 1 a.m. to 5 a.m. seemed to be the period of maximal melatonin effect on blood pressure, and this is very important, given the incidence of early morning cardiovascular events,” said Dr. Sharabi. No adverse effects were associated with melatonin, and compliance was high, he said.

In a separate study, vitamin E induced substantial increases in mean daytime and nighttime blood pressures in diabetic patients with hypertension, compared with those who were given a soy oil placebo, reported Dr. Ian B. Puddey of the department of medicine, University of Western Australia, Perth.

Although the supplements reduced oxidative stress, as indicated by consistent falls in urinary isoprostane (a marker of oxidative stress), this presumable benefit is nullified by the unexpected rise in systolic and diastolic pressures, as well as pulse pressure and pulse rate.

After a 3-week run-in period, 55 patients with type 2 diabetes and hypertension were randomized to placebo (soy oil stripped of all tocopherols), 500 mg/day of alpha-tocopherol, or 500 mg/day of mixed gamma-, alpha-, and delta-tocopherols. About half of the patients were on at least one antihypertensive drug; two-thirds were on lipid-lowering drugs.

“Contrary to our central hypothesis, we observed a small fall in blood pressure in the placebo group but increased mean pressures in both the alpha-tocopherol and mixed tocopherol groups,” said Dr. Puddey, who presented the data on behalf of the lead investigator, Dr. N.C. Ward. The mean increase was 7 mm Hg systolic and 5 mm Hg diastolic for the patients treated with vitamin E. The 24-hour ambulatory profile showed a sustained and consistent pressure increase throughout the day, with no diurnal variation.

MADRID — Melatonin supplementation can improve nocturnal blood pressure control and prevent early morning pressure surges in hypertensive patients who do not show the typical nighttime pressure drop, according to results presented at the annual meeting of the European Society of Hypertension.

But another dietary supplement—vitamin E—was shown to increase blood pressure in diabetic hypertensive patients in a second study reported at the meeting.

“Impaired nocturnal blood pressure fall is associated with increased risk of target organ damage related to hypertension,” said Dr. Yehonatan Sharabi of the Chaim Sheba Medical Center, Tel Hashomer, Israel, presenting the melatonin study.

It is not clear why some patients fail to show the usual nighttime pressure drop, but lack of melatonin, a hormone secreted by the pineal gland, may play a role. In patients with a blunted nocturnal blood pressure fall, the amount of urinary 6-sulfatoxymelatonin, the key metabolite of melatonin, is markedly reduced.

The Israeli team, with researchers at Gazi University, Ankara, Turkey, tested melatonin in 38 nonobese hypertensive patients already on one or more antihypertensive drugs. They were generally well controlled except for the impaired nighttime pressure fall and increased early morning pressure surges. Mean age was 64 years, with a range of 42–83 years. Those with insomnia were excluded.

After a 2-week placebo run-in period, the patients underwent baseline 24-hour ambulatory pressure monitoring, then were randomized to either 2 mg of controlled-release melatonin per day or placebo. They were instructed to take the assigned tablet 2 hours before bedtime. After 4 weeks, they underwent 24-hour monitoring. At baseline, the melatonin patients had mean morning pressures of 141/78 mm Hg and mean nighttime pressures of 136/72 mm Hg. The placebo group showed similar baseline values. There were no significant changes in daytime systolic pressure in response to melatonin. But nighttime pressures showed a mean drop of 7 mm Hg systolic and 3 mm Hg diastolic in the melatonin group. There was no such change in the placebo group.

“The time interval from 1 a.m. to 5 a.m. seemed to be the period of maximal melatonin effect on blood pressure, and this is very important, given the incidence of early morning cardiovascular events,” said Dr. Sharabi. No adverse effects were associated with melatonin, and compliance was high, he said.

In a separate study, vitamin E induced substantial increases in mean daytime and nighttime blood pressures in diabetic patients with hypertension, compared with those who were given a soy oil placebo, reported Dr. Ian B. Puddey of the department of medicine, University of Western Australia, Perth.

Although the supplements reduced oxidative stress, as indicated by consistent falls in urinary isoprostane (a marker of oxidative stress), this presumable benefit is nullified by the unexpected rise in systolic and diastolic pressures, as well as pulse pressure and pulse rate.

After a 3-week run-in period, 55 patients with type 2 diabetes and hypertension were randomized to placebo (soy oil stripped of all tocopherols), 500 mg/day of alpha-tocopherol, or 500 mg/day of mixed gamma-, alpha-, and delta-tocopherols. About half of the patients were on at least one antihypertensive drug; two-thirds were on lipid-lowering drugs.

“Contrary to our central hypothesis, we observed a small fall in blood pressure in the placebo group but increased mean pressures in both the alpha-tocopherol and mixed tocopherol groups,” said Dr. Puddey, who presented the data on behalf of the lead investigator, Dr. N.C. Ward. The mean increase was 7 mm Hg systolic and 5 mm Hg diastolic for the patients treated with vitamin E. The 24-hour ambulatory profile showed a sustained and consistent pressure increase throughout the day, with no diurnal variation.

WASHINGTON — Genomic science is advancing rapidly on many fronts, but without solid federal policy to prevent genetic discrimination, it will be very difficult for physicians and patients to harvest the fruits of researchers' labors, said Dr. Francis S. Collins, director of the National Human Genomic Research Institute, National Institutes of Health.

“All of the original goals of the Human Genome Project have been achieved,” the nation's “gene dean” said at the World Health Care Congress, a health policy conference sponsored by the Wall Street Journal. Genomic researchers are making clinically relevant and potentially cost-saving discoveries in early disease detection, pharmacogenomics, nutrigenomics, and rational gene-based drug design.

But he warned that widespread clinical application of these advances will remain a dream without adequate antidiscrimination safeguards.

“We really need this kind of protection to forward genomic medicine. The single greatest inhibition that people have about genomic medicine is the fear that the genetic information will be used against them. We've known about this hang-up for 10 years now,” Dr. Collins said. He and other leaders in the genomics field have repeatedly pushed for federal legislation that would guarantee nondiscrimination in employment or health insurance coverage decisions. Though such a bill has repeatedly been introduced, Congress has failed to come through.

One particular bill (S. 1053) died in the last Congress, and was reintroduced in the current Congress as S. 306 and HR. 1227, Dr. Collins said. Though it is technically still alive, he expressed doubt that either branch of Congress will move on it this year.

The hang-up? Dr. Collins said that many in the business community are concerned that this type of legislation would provide further chum for already voracious antidiscrimination attorneys, leading to an avalanche of spurious genetic discrimination lawsuits that could paralyze corporate America.

“Some of us are concerned that if someone doesn't start to move this soon, nothing will happen,” Dr. Collins said.

Dr. Elias Zerhouni, director of the National Institutes of Health, agreed. In a separate address at the conference, he said he shares Dr. Collins concern. “We really need antidiscrimination legislation.” Stasis on the policy front would be a tragedy, he continued, because genomic researchers are coming up with some pretty nifty clinical stuff these days.

Among the new advances, Dr. Zerhouni and Dr. Collins cited the evolution of the Hereditary Non-Polyposis Colon Cancer (HNPCC) screening panel that allows clinicians to predict the risk of colon cancer in families that have members with this type of colon cancer. According to a cost analysis published in 2001, HNPCC screening of individuals with the cancer costs roughly $42,000 per life-year gained. Not exactly a bargain, Dr. Collins admitted.

“But remember that each patient has relatives, and each first-degree relative has a 50% risk of developing the cancer,” he added. If you look at screening of parents, siblings and children of index cases, the cost drops dramatically to $7,556 per life-year gained (Ann. Intern. Med. 2001;135: 577). “This is much more cost effective, and it should be reimbursed.”

A multigene assay for predicting risk of recurrence in women with node-negative, tamoxifen-treated breast cancer is another bright light on the clinical genomics horizon. This assay can accurately identify which women are most and least likely to have positive long-term recurrence-free responses to tamoxifen chemotherapy (N. Engl. J. Med. 2004;351:2817–26). Its main virtue is that it allows patients who are unlikely to respond to tamoxifen to avoid undergoing the often unpleasant chemotherapy regimen.

The assay “has been widely adopted by many oncologists, and it has a big patient satisfaction benefit,” Dr. Collins said. But he acknowledged that the test is marginally cost efficient.

Another example from Dr. Collins: The emergence of assays to evaluate warfarin metabolism based on genetic variations in the function of the hepatic cytochrome P-450 (CYP-450) enzyme system has tremendous everyday potential for routine clinical practice. Assessment of the gene coding for CYP 2C9 can help physicians tailor warfarin doses to prevent bleeding episodes in patients with genetic propensities for higher-than-average responsiveness to the drug.

The test costs roughly $135 per patient, and can prevent one major bleeding episode for every 44 patients on warfarin (Am. J. Man. Care 2003;9:493–500). Prevention of a single severe hemorrhage using the genetic test would cost roughly $6,000, the approximate cost of managing a bleeding episode. So this test, by itself, is cost neutral, “but it is a major improvement in terms of patient outcomes,” said Dr. Collins, who called for a prospective trial on the subject.

According to Dr. Zerhouni, early detection of disease susceptibility years, if not decades, before symptoms emerge, and genomically guided drug therapy are the future of American medicine. “DNA sequencing costs are plummeting. This is opening up a new vista regarding our ability to understand disease.”

He said he believes genomic medicine is at a critical inflection point. “We have a lot of information. We need to exploit it to intervene, not at the most costly advanced stages of symptoms, but at early presymptomatic stages where we can truly prevent diseases from manifesting.”

Dr. Reed Tuckson, senior vice president for consumer health and medical care advancement at UnitedHealth Group, said there's a lot of public and physician education work that needs to be done before anyone will be able to make good on Dr. Zerhouni's vision.

“Physicians do not have time for abstract theoretical discourses on the genomics revolution. They want practical answers on how it applies to patient care and how it pertains to their daily practices. The learning systems need to meet these needs,” Dr. Tuckson said. He added that by and large, physicians and the health care system are not prepared to deal with the challenges of genomics.

WASHINGTON — Genomic science is advancing rapidly on many fronts, but without solid federal policy to prevent genetic discrimination, it will be very difficult for physicians and patients to harvest the fruits of researchers' labors, said Dr. Francis S. Collins, director of the National Human Genomic Research Institute, National Institutes of Health.

“All of the original goals of the Human Genome Project have been achieved,” the nation's “gene dean” said at the World Health Care Congress, a health policy conference sponsored by the Wall Street Journal. Genomic researchers are making clinically relevant and potentially cost-saving discoveries in early disease detection, pharmacogenomics, nutrigenomics, and rational gene-based drug design.

But he warned that widespread clinical application of these advances will remain a dream without adequate antidiscrimination safeguards.

“We really need this kind of protection to forward genomic medicine. The single greatest inhibition that people have about genomic medicine is the fear that the genetic information will be used against them. We've known about this hang-up for 10 years now,” Dr. Collins said. He and other leaders in the genomics field have repeatedly pushed for federal legislation that would guarantee nondiscrimination in employment or health insurance coverage decisions. Though such a bill has repeatedly been introduced, Congress has failed to come through.

One particular bill (S. 1053) died in the last Congress, and was reintroduced in the current Congress as S. 306 and HR. 1227, Dr. Collins said. Though it is technically still alive, he expressed doubt that either branch of Congress will move on it this year.

The hang-up? Dr. Collins said that many in the business community are concerned that this type of legislation would provide further chum for already voracious antidiscrimination attorneys, leading to an avalanche of spurious genetic discrimination lawsuits that could paralyze corporate America.

“Some of us are concerned that if someone doesn't start to move this soon, nothing will happen,” Dr. Collins said.

Dr. Elias Zerhouni, director of the National Institutes of Health, agreed. In a separate address at the conference, he said he shares Dr. Collins concern. “We really need antidiscrimination legislation.” Stasis on the policy front would be a tragedy, he continued, because genomic researchers are coming up with some pretty nifty clinical stuff these days.

Among the new advances, Dr. Zerhouni and Dr. Collins cited the evolution of the Hereditary Non-Polyposis Colon Cancer (HNPCC) screening panel that allows clinicians to predict the risk of colon cancer in families that have members with this type of colon cancer. According to a cost analysis published in 2001, HNPCC screening of individuals with the cancer costs roughly $42,000 per life-year gained. Not exactly a bargain, Dr. Collins admitted.

“But remember that each patient has relatives, and each first-degree relative has a 50% risk of developing the cancer,” he added. If you look at screening of parents, siblings and children of index cases, the cost drops dramatically to $7,556 per life-year gained (Ann. Intern. Med. 2001;135: 577). “This is much more cost effective, and it should be reimbursed.”

A multigene assay for predicting risk of recurrence in women with node-negative, tamoxifen-treated breast cancer is another bright light on the clinical genomics horizon. This assay can accurately identify which women are most and least likely to have positive long-term recurrence-free responses to tamoxifen chemotherapy (N. Engl. J. Med. 2004;351:2817–26). Its main virtue is that it allows patients who are unlikely to respond to tamoxifen to avoid undergoing the often unpleasant chemotherapy regimen.

The assay “has been widely adopted by many oncologists, and it has a big patient satisfaction benefit,” Dr. Collins said. But he acknowledged that the test is marginally cost efficient.

Another example from Dr. Collins: The emergence of assays to evaluate warfarin metabolism based on genetic variations in the function of the hepatic cytochrome P-450 (CYP-450) enzyme system has tremendous everyday potential for routine clinical practice. Assessment of the gene coding for CYP 2C9 can help physicians tailor warfarin doses to prevent bleeding episodes in patients with genetic propensities for higher-than-average responsiveness to the drug.

The test costs roughly $135 per patient, and can prevent one major bleeding episode for every 44 patients on warfarin (Am. J. Man. Care 2003;9:493–500). Prevention of a single severe hemorrhage using the genetic test would cost roughly $6,000, the approximate cost of managing a bleeding episode. So this test, by itself, is cost neutral, “but it is a major improvement in terms of patient outcomes,” said Dr. Collins, who called for a prospective trial on the subject.

According to Dr. Zerhouni, early detection of disease susceptibility years, if not decades, before symptoms emerge, and genomically guided drug therapy are the future of American medicine. “DNA sequencing costs are plummeting. This is opening up a new vista regarding our ability to understand disease.”

He said he believes genomic medicine is at a critical inflection point. “We have a lot of information. We need to exploit it to intervene, not at the most costly advanced stages of symptoms, but at early presymptomatic stages where we can truly prevent diseases from manifesting.”

Dr. Reed Tuckson, senior vice president for consumer health and medical care advancement at UnitedHealth Group, said there's a lot of public and physician education work that needs to be done before anyone will be able to make good on Dr. Zerhouni's vision.

“Physicians do not have time for abstract theoretical discourses on the genomics revolution. They want practical answers on how it applies to patient care and how it pertains to their daily practices. The learning systems need to meet these needs,” Dr. Tuckson said. He added that by and large, physicians and the health care system are not prepared to deal with the challenges of genomics.

WASHINGTON — Genomic science is advancing rapidly on many fronts, but without solid federal policy to prevent genetic discrimination, it will be very difficult for physicians and patients to harvest the fruits of researchers' labors, said Dr. Francis S. Collins, director of the National Human Genomic Research Institute, National Institutes of Health.

“All of the original goals of the Human Genome Project have been achieved,” the nation's “gene dean” said at the World Health Care Congress, a health policy conference sponsored by the Wall Street Journal. Genomic researchers are making clinically relevant and potentially cost-saving discoveries in early disease detection, pharmacogenomics, nutrigenomics, and rational gene-based drug design.

But he warned that widespread clinical application of these advances will remain a dream without adequate antidiscrimination safeguards.

“We really need this kind of protection to forward genomic medicine. The single greatest inhibition that people have about genomic medicine is the fear that the genetic information will be used against them. We've known about this hang-up for 10 years now,” Dr. Collins said. He and other leaders in the genomics field have repeatedly pushed for federal legislation that would guarantee nondiscrimination in employment or health insurance coverage decisions. Though such a bill has repeatedly been introduced, Congress has failed to come through.

One particular bill (S. 1053) died in the last Congress, and was reintroduced in the current Congress as S. 306 and HR. 1227, Dr. Collins said. Though it is technically still alive, he expressed doubt that either branch of Congress will move on it this year.

The hang-up? Dr. Collins said that many in the business community are concerned that this type of legislation would provide further chum for already voracious antidiscrimination attorneys, leading to an avalanche of spurious genetic discrimination lawsuits that could paralyze corporate America.

“Some of us are concerned that if someone doesn't start to move this soon, nothing will happen,” Dr. Collins said.

Dr. Elias Zerhouni, director of the National Institutes of Health, agreed. In a separate address at the conference, he said he shares Dr. Collins concern. “We really need antidiscrimination legislation.” Stasis on the policy front would be a tragedy, he continued, because genomic researchers are coming up with some pretty nifty clinical stuff these days.

Among the new advances, Dr. Zerhouni and Dr. Collins cited the evolution of the Hereditary Non-Polyposis Colon Cancer (HNPCC) screening panel that allows clinicians to predict the risk of colon cancer in families that have members with this type of colon cancer. According to a cost analysis published in 2001, HNPCC screening of individuals with the cancer costs roughly $42,000 per life-year gained. Not exactly a bargain, Dr. Collins admitted.

“But remember that each patient has relatives, and each first-degree relative has a 50% risk of developing the cancer,” he added. If you look at screening of parents, siblings and children of index cases, the cost drops dramatically to $7,556 per life-year gained (Ann. Intern. Med. 2001;135: 577). “This is much more cost effective, and it should be reimbursed.”

A multigene assay for predicting risk of recurrence in women with node-negative, tamoxifen-treated breast cancer is another bright light on the clinical genomics horizon. This assay can accurately identify which women are most and least likely to have positive long-term recurrence-free responses to tamoxifen chemotherapy (N. Engl. J. Med. 2004;351:2817–26). Its main virtue is that it allows patients who are unlikely to respond to tamoxifen to avoid undergoing the often unpleasant chemotherapy regimen.

The assay “has been widely adopted by many oncologists, and it has a big patient satisfaction benefit,” Dr. Collins said. But he acknowledged that the test is marginally cost efficient.

Another example from Dr. Collins: The emergence of assays to evaluate warfarin metabolism based on genetic variations in the function of the hepatic cytochrome P-450 (CYP-450) enzyme system has tremendous everyday potential for routine clinical practice. Assessment of the gene coding for CYP 2C9 can help physicians tailor warfarin doses to prevent bleeding episodes in patients with genetic propensities for higher-than-average responsiveness to the drug.

The test costs roughly $135 per patient, and can prevent one major bleeding episode for every 44 patients on warfarin (Am. J. Man. Care 2003;9:493–500). Prevention of a single severe hemorrhage using the genetic test would cost roughly $6,000, the approximate cost of managing a bleeding episode. So this test, by itself, is cost neutral, “but it is a major improvement in terms of patient outcomes,” said Dr. Collins, who called for a prospective trial on the subject.

According to Dr. Zerhouni, early detection of disease susceptibility years, if not decades, before symptoms emerge, and genomically guided drug therapy are the future of American medicine. “DNA sequencing costs are plummeting. This is opening up a new vista regarding our ability to understand disease.”

He said he believes genomic medicine is at a critical inflection point. “We have a lot of information. We need to exploit it to intervene, not at the most costly advanced stages of symptoms, but at early presymptomatic stages where we can truly prevent diseases from manifesting.”

Dr. Reed Tuckson, senior vice president for consumer health and medical care advancement at UnitedHealth Group, said there's a lot of public and physician education work that needs to be done before anyone will be able to make good on Dr. Zerhouni's vision.

“Physicians do not have time for abstract theoretical discourses on the genomics revolution. They want practical answers on how it applies to patient care and how it pertains to their daily practices. The learning systems need to meet these needs,” Dr. Tuckson said. He added that by and large, physicians and the health care system are not prepared to deal with the challenges of genomics.