A trustworthy service is more important than ever

Then came the disappointment. They couldn’t understand his instructions. There were extras he didn’t ask for and didn’t need. The price was higher than advertised, plus there were hidden fees. Later, he found out it was twice what locals paid for the same thing. He couldn’t believe this was the place that had been recommended on the internet. And that was the worst part: it wasn’t. The taxi driver had been paid to take him to a competitor.

The medical tourism bazaar

A Bangkok tailor? A Turkish rug merchant? The story of a tourist being taken is as old as tourism itself. But today it has a new form. The story can now apply to medical tourists searching for treatment in a sometimes chaotic, often intimidating new bazaar of international health providers.

When we hear of a naive American who thought he could buy a genuine Nikon at half price, we laugh. Do we feel the same about the Ethiopian family who sold their farm to afford cancer treatment for their 83 year old father? Or the Australian woman who believed an unproven stem cell treatment could cure her diseased heart?

Innocents abroad

Medical tourism has become much more than a quick trip across the border for inexpensive dentistry, or that tropical-vacation-with-a-facelift. This year millions of people will board planes to seek more reliable diagnoses and effective treatments than they can get at home. Many will start with a comprehensive check-up. Others are already in pain, urgently needing treatment for spine problems, arthritic knees, or a weak digestive system. Some suffer from chronic diseases like hypertension or diabetes. Many will be searching for a doctor they can trust with a crucial diagnosis: “Why is my son so tired and weak?” “Should I have surgery on my brain tumour, or try radiation therapy?”

Despite the high stakes, there are no standard procedures such as those that allow planes from one country to navigate and land safely in another. Conscientious organizations, websites and authors try to help patients make informed decisions. But an international patient may not be able to find them among the hundreds of agents and websites that are more interested in selling than healing.

What is needed more than anything is for hospitals that serve international patients to adopt transparent practices.

Why the need for hospital transparency?

Reason 1: Patients are travelling for healthcare they can trust.
The reason many patients leave home is a lack of transparency and trust in their own medical systems. The hospital where I work probably serves more serious medical travellers than any other. They tell us the biggest reason they come is they cannot find capable, trustable medical resources in their own countries.

However, many of the top medical destination countries do not rank high in perceived transparency. Will a patient travelling to India, Turkey, Thailand or Mexico automatically trust institutions there? No. These countries are popular tourist destinations but they do not enjoy the image of a Switzerland or Sweden.

If transparency is not a perceived characteristic of the market a hospital operates in, then it has to work extra hard to be an exception to the perception.

Reason 2: Healthcare is a complicated product
It is not easy to be transparent. Indeed, the US ranks high on transparency, but its byzantine healthcare system is anything but transparent. Layers of intermediaries separate patients from their doctors, making it surprisingly difficult to answer the most basic questions about allowed treatments and estimated costs.

Medical travellers need clear answers. They are not equipped to navigate the complexities of a foreign country’s healthcare system. They want to know what treatment they can get, who will care for them, how long it will take and how much it will cost.

So what exactly do hospitals need to be transparent about? More clarity, honesty and fairness are needed in four areas: Quality, Doctors, Costs and Treatment.

Quality: Trusting what goes on behind the scenes

Even in the most medically advanced countries, hospitals are not always safe places. Risks from hospital acquired infections, medication errors, falls and other mishaps require constant attention.

The problem is that most of this goes on behind the scenes. Do patients see how medications are distributed, surgical instruments sterilized, staff trained? Not usually – and even if they did, they might not recognize poorly-managed processes.

This is why accreditation is so important. The first step in transparency is for a hospital to invite review by a reputable, third party accreditor like the Joint Commission International. JCI surveyors look behind the scenes to evaluate what patients cannot. When Bumrungrad Hospital first invited a JCI survey in 2002, no other Asian hospital had JCI accreditation. Now there are many, attesting to the importance of third party review.

The best hospitals go beyond accreditation. They track quality measures like falls, unplanned re-admissions, and patient complaints, and make them visible to their staff. They participate in bench-marking like the International Quality Improvement Project. They share quality statistics with patients who want to know. And they welcome comments in social media. They are more eager to know what they can improve, than fearful of criticism.

We also support the efforts of diligent, independent journalists like Patients Beyond Borders, who visit hospitals and advise patients how to be smart consumers.

Who is my doctor?

Medical travellers may fly thousands of kilometres to a hospital they have never seen, for treatment by a doctor they have never met. One of the most important ways a hospital can help is to provide information about its doctors. For example:

•     What are their credentials?
•     What languages can they communicate in?
•     Where did they go to medical school and get advanced training?
•     Have they been board certified in the US or other countries?

Bumrungrad offers over 1,000 doctors representing virtually every specialty, and we put their information on our public website. Many hospitals now do this. If a hospital wants to serve international patients, it must.

Medical travellers have a right to expect a high degree of integration between the hospital and its doctors. Patients’ bills should include all doctors’ charges. The hospital should have guidelines and exercise oversight to assure patients that doctors’ fees are consistent and reasonable.

Doctors’ financial incentives should reward hard work, expertise and patient loyalty – not “selling” things such as procedures, referrals, or medicines. For private hospitals, patients benefit when a hospital’s ownership is independent from its doctors, so that doctors are not involved in the “business” of the hospital.

Trusting the cost of medical travel

Medical travellers want to know how much treatment will cost before they travel. This is a hard question to answer before the patient arrives at the hospital and is evaluated by its doctors. Each patient and treatment plan is different.

Hospitals and medical travel facilitators have developed different solutions to this challenge. They don’t all pass the transparency test.

A common solution is the “package price.” The “total knee package” might cost $12,000. Or the “CABG package”, $19,000. Package prices make it easy to buy. But they assume the same treatment for all patients, and they invariably include a lot of fine print. If you are not an average patient, you may not qualify. Even if you are, you may find added costs that weren’t part of the package.

A more troubling tactic is raising prices to allow attractive discounts. We have seen hospitals offering discounts and referral commissions in excess of their profit margins. Are they willing to lose money to attract business? Not usually. One often finds they have introduced a higher price tier for international patients – sometimes as much as double the prices for local patients.

We think international patients should pay the same prices as locals. Our hospital does not add any surcharges for international services like interpreters. If a hospital chooses to do so, the charges should be clear.

Cost estimates should be provided after the patient is evaluated by the treating physician. The patient can then approve the recommended treatment plan and cost estimate before proceeding.

Still, international patients like to have an approximate idea of costs before they buy their plane tickets. Five years ago, we introduced a service called REALCOST. For the most common procedures, it looks up what our patients paid upon discharge over the past year and provides descriptive statistics on our website. Prospective patients can see the median and range of actual costs for the treatment they are considering. (If a treatment is not listed, a patient can email us about their condition and we will do our best to provide a cost range).

We are surprised more hospitals don’t do this. Is it because they don’t know their costs, or because they are unwilling to share them? All hospitals who aim to serve international patients should be transparent about their costs. Patients do not simply choose the cheapest option. They will, however, favour hospitals that provide honest, helpful information.

Trusting the treatment

Good hospitals are transparent about the benefits and risks of treatment. Destination medical centres have special ethical obligations in this regard, because some medical travellers seek advanced or experimental treatments that are not yet available in their home countries. There is a fine line between providing hope for people with desperate medical problems, and exploiting their desperation for profit.

We have a couple of useful guidelines at our hospital. First, we recommend clinically proven treatments. If a patient wants to be considered for an experimental treatment, it should be part of a sanctioned clinical trial. The patient should be clearly informed and formally authorize it.

Second, we try our best to discourage terminal cases from flying to Bumrungrad. It is a credit to our doctors that families in some of our patient source countries believe we can perform miracles. But we cannot in good conscience accept such cases when little can be done.

At Bumrungrad, we also have an international medical coordination office, staffed by over 100 doctors, nurses and administrators, who review significant international patient cases before they arrive. They assess if we can help a patient and recommend which specialists are best suited for the case. They review the patient’s medical records, discuss them with the assigned doctors, and set up a schedule for evaluation and treatment. The coordination team includes expatriates who understand patients’ native languages and cultures.

This team also helps patients and their sponsoring organizations make smart decisions about how long to stay in the hospital, how long to stay in Bangkok for follow-up treatment, and when it is safe to return home. They help to advise local providers on care after the patient returns home. In short, they help the hospital serve the patient, and the patient get what they need from the hospital.

These responsibilities cannot be offloaded to facilitators or busy clinicians. Any hospital serious about caring for international patients needs a full-functioning coordination team. If overseas inquiries are answered immediately with a short boilerplate “…we will be glad to treat you,” it may show the hospital is more interested in getting patients than delivering effective treatment.

Transparency is trust

Many people assume that the medical traveller only crosses borders for treatment once in a lifetime. Not true. About 40% of our fly-in patients are repeat patients. They come back because they trust us with their serious medical problems.

Transparency should be the cornerstone of any hospital’s medical destination strategy, because a primary customer need is the need for trust. Transparency is not easy because healthcare is complicated and each patient is unique. It requires objective assurance of quality and safety; honest information about doctors and costs; careful coordination, and patient-centred treatment. It requires pioneering hospital leaders to cut through complexity, think like a patient, and make their institutions easier to buy and trust. Even from half a world away.