The overseas pa­tient trap

Sys­tems face lan­guage, cul­tural dif­fer­ences tend­ing to health tourists’ needs

Modern Healthcare - - OPINIONS COMMENTARY - Steven J. Thompson Steven J. Thompson is CEO of Johns Hop­kins Medicine In­ter­na­tional and se­nior vice pres­i­dent of Johns Hop­kins Medicine, Baltimore.

With pres­sure grow­ing on hospi­tal sys­tems to find new sources of rev­enue, many health­care ex­ec­u­tives are turn­ing to in­ter­na­tional pa­tients as an at­trac­tive op­tion. A sub­stan­tial num­ber of overseas pa­tients are will­ing and able to come to the U.S. for di­ag­no­sis and treat­ment. They typ­i­cally are pa­tients with more com­plex dis­or­ders from coun­tries where high-level spe­cialty care may not be read­ily avail­able. More im­por­tantly, they can af­ford to pay for their care out of pocket or have their care fully funded by their gov­ern­ments or pri­vate in­surance.

It’s a tempt­ing busi­ness. But rev­enue is only part of the pic­ture. Any health­care ex­ec­u­tive who starts with dol­lar signs danc­ing in their eyes is in for a shock. The real chal­lenge in es­tab­lish­ing a thriv­ing in­ter­na­tional pa­tient busi­ness is mod­i­fy­ing some, if not most, as­pects of a hospi­tal’s ba­sic in­fra­struc­ture.

Some of the hospi­tal sys­tems that have suc­ceeded in this mar­ket, in­clud­ing Cleve­land Clinic, Mayo Clinic and Johns Hop­kins Medicine, had the large ad­van­tage of in­ter­na­tional name recog­ni­tion. Yet even they strug­gled to meet the unique de­mands and re­al­i­ties of serv­ing this non­tra­di­tional mar­ket.

Serv­ing in­ter­na­tional pa­tients even­tu­ally turned out to be prof­itable for Johns Hop­kins, where I work. But we had to in­vest mil­lions of dol­lars in the early years in staffing, pro­gram devel­op­ment and mar­ket­ing.

Here are some of the hur­dles that hospi­tal sys­tems will face in car­ing for in­ter­na­tional pa­tients and some of the ap­proaches Johns Hop­kins Medicine took to get over them: Lan­guage.

Now that the abil­ity to ac­com­mo­date non-English-speak­ing pa­tients is part of the Joint Com­mis­sion ac­cred­i­ta­tion process, U.S. hos­pi­tals are learn­ing how ex­pen­sive and tricky pro­vid­ing trans­la­tion ser­vices can be. The chal­lenges are mul­ti­plied when try­ing to serve a num­ber of in­ter­na­tional pa­tients, whose lan­guages and di­alects may be more var­ied than those nor­mally en­coun­tered; who fre­quently have lit­tle ex­pe­ri­ence cop­ing with a lan­guage bar­rier; and who may not have fam­ily and friends around to lend sup­port.

Johns Hop­kins has a small army of in­ter­preters on tap, but found even that’s not enough to en­sure a good pa­tient ex­pe­ri­ence. While in­ter­pre­ta­tion cre­ates a tem­po­rary bridge be­tween pa­tient and care­giver, a stronger health­care part­ner­ship is formed when the care­giver speaks the pa­tient’s lan­guage. For that rea­son, we in­creased hir­ing of physi­cians, nurses and ad­min­is­tra­tive staff who speak other lan­guages, and sup­ported lan­guage train­ing for those will­ing to learn.

Cul­ture. Al­most ev­ery ba­sic as­sump­tion clin­i­cians and ad­min­is­tra­tors make about how to man­age pa­tient care goes out the win­dow when work­ing with pa­tients from other coun­tries. Among the chal­lenges Johns Hop­kins rou­tinely en­coun­ters: pa­tients who come from cul­tures where its peo­ple rou­tinely ar­rive hours late for ap­point­ments yet ex­pect im­me­di­ate at­ten­tion; pa­tients who pre­fer that clin­i­cians ad­dress all com­ments and leave all de­ci­sions to hus­bands or par­ents or even young male chil­dren; pa­tients who won’t re­move cloth­ing for ex­ams; and much more.

In­sist­ing that pa­tients and their fam­i­lies do things “our way” is a non­starter. Though it of­ten takes cre­ativ­ity to do it, Johns Hop­kins found there are al­ways ways to re­spect­fully ac­com­mo­date cul­tural ex­pec­ta­tions with­out com­pro­mis­ing the de­liv­ery of top-notch care or vi­o­lat­ing eth­i­cal stan­dards.

Lo­gis­tics. Rou­tine pro­cesses such as sched­ul­ing tests, get­ting a pa­tient into a con­va­les­cent fa­cil­ity and ar­rang­ing for post-dis­charge care can all be­come night­mares when deal­ing with a pa­tient who can stay in the U.S. for only a rel­a­tively short time. We devel­oped spe­cial ap­point­ment-mak­ing pro­cesses de­signed to ac­com­mo­date the com­pressed sched­ules and un­cer­tain needs of th­ese pa­tients, and stud­ied the work­ings of health­care sys­tems in dozens of coun­tries so that we can smoothly tran­si­tion our pa­tients into ap­pro­pri­ate fol­low-up care, com­plete with med­i­cal records.

Then there are travel ar­range­ments for pa­tients and lodg­ing for fam­ily and post-dis­charge pa­tients. Pa­tients of­ten won’t travel to a hospi­tal that won’t take care of th­ese lo­gis­tics. The job can be out­sourced, but few out­side firms have the abil­ity to closely co­or­di­nate with a com­pli­cated and of­ten rapidly chang­ing med­i­cal sched­ule. It took in-house travel ex­perts to make sure it was done right. Billing.

Overseas pa­tients and pay­ers will shop around—and ex­pect rapid fi­nan­cial es­ti­mates and con­sol­i­dated billing for the en­tire ex­pe­ri­ence. That in­cludes not only all physi­cian, med­i­ca­tion, lab and fa­cil­i­ties costs, but of­ten travel costs and con­va­les­cent and fol­low-up care. Ty­ing it all to­gether can be la­bo­ri­ous and re­quires some ex­per­tise as well as spe­cial­ized soft­ware. Mean­while, col­lect­ing from overseas pay­ers is typ­i­cally a unique process in ev­ery coun­try and gen­er­ally very dif­fer­ent from the U.S. Learn­ing the ins and outs takes time and ef­fort, and rev­enue will be di­min­ished while do­ing

so. Mar­ket­ing. Yes, mar­ket­ing is part of the puz­zle, too. This isn’t a “build it and they will come” propo­si­tion. In­ter­na­tional brand aware­ness, rep­u­ta­tion and part­ner­ships must be care­fully and pa­tiently nur­tured, re­gion by re­gion. One way Johns Hop­kins got up to speed was by send­ing a num­ber of key ex­ec­u­tives and clin­i­cal lead­ers to health­care con­fer­ences all over the world, mak­ing con­tacts and ask­ing a lot of ques­tions. There were no short­cuts; it took years.

Even hos­pi­tals that are up to the mar­ket­ing chal­lenges will be bet­ter off if they fo­cus first on pro­vid­ing good ser­vice to a small num­ber of overseas pa­tients and slowly build the in­sti­tu­tion’s word-of-mouth rep­u­ta­tion. Striv­ing to bring in a flood of pa­tients right away will only cre­ate pa­tient-ex­pe­ri­ence dis­as­ters that will per­ma­nently dam­age a hospi­tal’s global rep­u­ta­tion.

Serv­ing in­ter­na­tional pa­tients

can be prof­itable.

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