Ori Karev is CEO of UnitedHealth International, the leading global health and well-being company.
both presentations to the 2nd International Medical Travel Conference
in Washington DC in December 2007 and in white papers, Mr. Karev has
been willing to address the crucial issues affecting medical travel.
IMTJ asked him about the current challenges to widespread acceptance of
medical travel by the US market, and possible solutions.
"We see our role as
providing our members with the best possible outcome relative to the three most
critical components of healthcare: access, affordability and quality. The
environment in the US is
such that there are large groups today that either by necessity or choice are
looking outside the US for healthcare. For example, retirees all over the world are moving to where
it’s warm and less expensive, and healthcare is clearly a component of that
decision. And then there are large communities who are uninsured for other
reasons who are looking for affordable, high quality treatment.
The US is a potentially large market given its
wealth and mobility, and one which is perhaps not widely understood outside the
At present, those Americans who receive treatment outside the US are the uninsured, those whose
health plan co-payments or deductions are extremely high or those who travel
for cultural or country-of-origin reasons. Insured Americans may at times question
their care, but they are not yet likely to make the leap of seeking healthcare
overseas. It follows, then, that it is the payors that should drive the international
coordination of high quality healthcare for their members at an affordable
For this to occur,
there needs to be a greater degree of integration between global healthcare
providers and the US
healthcare system, particularly when non-cash transactions are involved. The US healthcare
system is not a cash economy. In most cases, the only cash paid out by US
patients to a medical facility or other health care provider is towards their
out-of-pocket co-payments. So international facilities and other health care
providers must be networked with and tied financially to payors to facilitate
the efficiency and ease of receiving treatment outside the US. This shouldn’t be difficult to
achieve, provided that the international facility is able to contract directly
with a payor environment.
needs to be a common data infrastructure and effective linkages. There is an
inherent challenge in transporting critical clinical data - patient history,
diagnosis of the presenting concern, prescription drug use, etc. - between
countries. From a data infrastructure viewpoint, clinical data must be readily
transportable (HIPPA implications notwithstanding) so that the patient, the
treating physician, the examining physician, and the payor all have access. What
is sometimes forgotten is that care coordinators and payors must also be able
to access this information to coordinate care and pay the bills when the
patient returns to his country of origin. Personalised and transportable
electronic health records are also critical to understanding costs and
determining future insurance premiums, both locally and globally.
Again, this obstacle
can be overcome. At present there is an international facility overseas which
produces data which is clearly usable by the payor systems in the United
States, but there is a disconnect which will only be solved when the US
healthcare system and the non-US facilities join forces to provide a shared
data infrastructure. This is particularly important to insurers since costs in
previous years allow us to project the cost of healthcare in future years. If
the data collected is incomplete or inconsistent, then there is a long term
actuarial challenge in continuing to support the activities overseas.
Third, there is a
current absence of an integrated, international legal framework. The US is a
litigious society. Related to the healthcare market, our liability legislation
and massive body of common law clearly establish the patients’ right to sue if
they feel they have been wrongfully treated. It is this specific right (or perhaps
even a sense of entitlement) which gives rise to the need for US medical
providers to over-test, over-prescribe and practice defensive medicine. The
fear of one's medical decisions being challenged down the road, with the
benefit of hindsight and a good legal counsel, drives US providers to seek sometimes
extraordinary treatments, procedures and advice. This approach costs money.
Accordingly, a portion of the high costs of US health care is the cost of
protecting against litigation.
background in mind, receiving medical treatment outside the US offers interesting challenges.
The first has to do with conflicts of law. Let's provide an example. As
Americans we have contractual and natural law expectations of how we will be
treated and informed during the health care process. If we see a Web site
offering treatment outside the US and opt to receive this treatment, does that
mean that US law applies if we want to sue for negligence performed in that
country? Do we have the right to sue under the laws of the country where
treatment was rendered? Do any of our expectations as US citizens have legal
strength in the country where we were treated?
Clearly, there are
conceivable commercial solutions to such legal obstacles. However, finding
solutions may first require testing our assumptions through global legal
challenges and court rulings.
Last, there is
currently a lack of availability of country-of-origin support systems. At some
point, most patients who receive treatment overseas will return home with
ongoing health needs relative to their recovery that require clinical support.
Outside of the legal considerations, the fundamental issue is ensuring that a
returning patient has access to the clinical support they need to continue
their recovery. It is too early to tell whether US clinicians will be fully
supportive of their patients who have received treatment overseas, but let’s
assume that this is the case. Even the best intentioned, fully supportive
providers will have a need for data, assessments and support to provide for
appropriate continuity of care.
and infrastructural business solutions can be developed to address this issue.
Medical travel is
in vogue, and because it is a largely consumer-driven phenomenon, suppliers
across the world are preparing themselves to meet demand and, in many cases, are
actively promoting it. Country-of-origin providers of care may begin to accept
that their patients are increasingly interested in services outside the home
country. What are lacking are the processes and infrastructures required to
facilitate and enable this growing movement. But the challenges outlined here
may not be as difficult as they appear. Many of the tools are resident in our
system of health care intermediaries: care coordination, provider-payor
contractual arrangements, claim payment and customer service, are all skills
that can be applied to global health care delivery.
Trends such as
global health care move inevitably and inexorably. In the end, they are
destined to provide more individuals with more access and more choices. That is
the imperative. Facilitating this movement is the responsibility of and
opportunity for every stakeholder involved in this growing industry. Our
challenge is to recognize the needs, demands and opportunities of medical
travel and continue the global dialogue required to address them.