Next steps in Health Tourism Destination Development – Centers of Excellence and Referral Networks

Health Tourism, Cross Border Healthcare, Medical Tourism, and all the other market accepted and proprietary phrases used to describe when someone travels outside their local community to access healthcare needs more than an empty bed in a reference hospital that will admit them.

Health Tourism, Cross Border Healthcare, Medical Tourism, and all the other market accepted and proprietary phrases used to describe when someone travels outside their local community to access healthcare needs more than an empty bed in a reference hospital that will admit them.  Establishing a medical tourism destination program is much more than finding some excess capacity beds at a private or teaching hospital and circling the wagons.

The History Lesson

If destination cluster-building were the answer to building a medical tourism sector, some destinations that have paid a lot of money to consultants in the past would be much further along in their success as a brand, as a destination, and as the “go to” referral cluster in a given region. Clearly, that hasn’t happened in any big way. There are many reasons I could attribute to this, but some stand out more than others.

In hindsight, what is now clear is that some consultants came with ulterior motives, some of which were not in the clients’ best interests.  These short-sighted motives included simply taking fees from a client who didn’t know better (predatory, at best) appealing to egos by convincing government organizers to approve expenditures to prematurely market the quickly organized cluster so that they could sponsor a stand at various trade shows. In a developing niche, these things happen. There’s no crime, decision-makers make mistakes sometimes. It’s just part of the learning curve. I could name many destinations of which this sad tale is exactly what happened, but that’s not really important, is it? What is important is that they recover and pick themselves up, dust themselves off and conquer what’s next.

There were also internal constraints. Some markets have very competitive natures, and individual rival hospitals and providers cannot seem to get along well enough to pull together for the sake of all competitors in an effort to build “coopetition”.  Others lack sufficient budget and no real compelling reason for a Board of Trustees of a hospital to allocate more. Still others lack the leadership or politicians with the insight, willingness or budget resources to organize some public-private partnership (PPP) effort.

Then there’s the apathy. Private hospitals think the government should market the destination while they manage marketing the hospital. Doctors get frustrated with the whole lot of the politicians and the hospital executives and do their own maverick initiatives. Tourism boards think that they are already doing what they should because they don’t really know what else to do. Ministries of Health are not all that concerned with medical tourism because they are charged with the responsibility to license and regulate providers and health facilities, measure quality and ensure safety, and manage health risk in the event that someone travels to the region and brings with them some communicable disease which could create a pandemic. Secretaries of higher education haven’t been clued in on what is needed to build capacity to attract health pilgrims to the region, so they keep producing nurses and technicians with the same skills they always have.

Clearly, what’s missing here is someone who knows how to put all the pieces together, set public policy, establish a framework law that regulates the quality, safety, and market practices, attracts investors to bring innovation to the destination, and guide providers on how to market and deliver high-quality, safe patient care.

The Next Step

For health tourism to evolve to the next level, the destination must come together with key decision-makers from all the touchpoints in the market niche that hope to play a role.  Together they must form a task force that is assigned the duty to investigate the current state of play in the market, define and articulate the objectives of the program, obtain consensus from the market leaders, allocate the kickstart budget to complete the investigation and write the Terms of Reference (TORs) and find and vet the proper assistance.  That’s where the first difficulty arises.  There are very few experienced consultants that can assist with this kind of guidance. I know because I am one of them and my community of experts in this domain is extremely small.

The task force should be charged with the responsibility to perform the research into what exists as current assets and what can be turned into an asset with a little effort.  It should also be responsible for the development and publication of specific criteria to establish, measure, monitor, and regulate a health tourism destination reference network.

To accomplish this, the task force must facilitate the exchange of information and locate the expertise on the establishment of the networks, not just theoretically or administratively on paper, but down to the very core of operations.  This is also where many will encounter difficult, because there are few experienced consultants with this kind of hands-on experience.

I am one of a very small group of experts in medical tourism that has done this type of a project, both in and outside of health tourism. I developed the word’s first and only “globally integrated health delivery system®” which was granted a trademark registration for a new term of art by the US Patent and Trademark Office (USPTO) in Washington. But since 1991, I also designed and launched over 200 such integrated health delivery systems that combine unaffiliated corporately owned private hospitals, university teaching hospitals, public hospitals and aligned independent and employed physicians.

I also have the experience and battle scars from designing and implementing and serving as operations manager, the management services nexus that coordinates the operations of each of these entities, enabling coordinated care, coordinated information systems, and coordinated quality measures across these networks of otherwise unaffiliated independent physicians and hospitals and other healthcare providers (lab, ambulance, home care, imaging, mental health, etc.) I also authored the leading book about development integrated health tourism provider networks back in 2011, published in 2012. The material inside the Handbook of Medical Tourism Program Development came from years of hands on experience, trial and error, and refined best practices.  But I didn’t just start off by writing a book from recent experiences. Prior to the release of that book, I authored two other books on building integrated health delivery systems, the first in 1996, published by McGraw Hill in 1997, titled IPA, PHO, MSO Development Strategies and later, Physician Integration and Alignment: IPA, PHO, MSO, ACOs and Beyond, published by Productivity Press in 2013. Few others can lay claim to the experience it takes to build this kind of reference network for cross border healthcare.

For any health tourism or cross-border program to move to the next level, there must be some act that authorizes a regulatory body to establish criteria and conditions that healthcare providers and other supplier (hotel, restaurant, ground transportation, etc.) wishing to join the network must fulfill. With such an official Act, no one will take the criteria or conditions seriously and the development turns from organized efforts to a free-for-all that is near impossible to steer in a direction of organized growth, or to require or measure compliance and apply continuous quality and safety improvement efforts.

The second is to design the operation of such a network of regulated providers to coordinate their actions toward a planned objective while preserving their rights to and encouraging innovation, free-market competition, and investment in the sector and its supply chain.

In health tourism, there is no such set of standards known to exist, nor is there any off-the-shelf accreditation that could even be wrapped around the needs of such a reference network entity and tweaked to make it fit. For healthcare in general (not specifically for cross-border healthcare), there are several accreditation programs in existence, but they all focus on individual health facilities, not groups of unaffiliated providers. Each of these must be accredited by an accrediting body that accredits the accreditor. In healthcare, thus far, at an international level, this is done by the International Society of Quality (ISQua). Accredited surveyors from accredited programs such as Joint Commission International (JCI), Accreditation Canada,  focus on ensuring that a facility already has its operational and quality standards, and they survey through external validation, the actual implementation of the standards, policies and procedures by performing tracer method surveys to ensure that the facility “walks its talk”; nothing more.

Decisions, Decisions, Decisions!

From what I know of having done deep dive inspections of hospitals and provider clusters across many health tourism destinations, many are either in the process of developing such systems, or are yet to start the process at all. There are few examples of national and regional health clusters that possess the functionality to operate across independent providers.  For example,

  • Some focus on a specific disease or condition such as heart ailments or orthopedic conditions
  • Few use formally-developed, secure communication telehealth services to connect with patients prior to arrival or post-discharge when they return to their home communities. (They often use Skype or other unsecured similar tools).
  • Few have formalized guidelines or metrics adopted or embraced by the entire network – especially if the network is constructed of providers that work for more than one corporate brand.
  • Some of the criteria for prospective providers to gain entry and become suppliers of the reference network have little if any baseline criteria upon which they are evaluated in order to join in.

In order to develop criteria for network design, the first thing that must be determined is the client persona upon which the network’s prime objectives should be focused:

Generally there are three sub-categories of criteria:

  • Persons with targeted diseases or conditions who need costly, highly-specialized, complex diagnosis and treatment, specialized equipment that is unaffordable to most health facilities and requires specialized physician and technician training and equipment or support systems;
  • A clinically- integrated, multi-disciplinary, aligned group of healthcare providers that can together supply a particular concentration of expertise and resources unavailable without requiring the patient to return frequently or to travel between clinics to achieve what a clinically-integrated health delivery system can easily achieve in one place, during one visit.
  • Where low prevalence, low incidence, complex cases can be attracted to take advantage of a Center of Excellence environment with higher volumes of cases bring with them the ability to attract the experts that would otherwise only draw in one or two cases per year, or less.

In each decision, it is critical to take into account the assets, the known needs of the citizens, and to address what is of greatest priority in the region, rather than what is hoped for in the pot of gold at the end of the phantasmagorical medical tourism rainbow.

Network Development Functionality

On its face, such a network can be theorized to work if one addresses key concerns such as:

  • Credentialing and privileging of network providers
  • Business continuity, contingency planning and response capacity
  • Framework and policies on quality, patient safety and evaluation
  • Framework of patient care, clinical tools and health technology assessment
  • Information system, data protection, technology and e-health tools and applications
  • Overall framework and capacity for staff training and development
  • Logistics coordination for medical pilgrims and their companion travelers, no matter the distance traveled
  • Overall organization and management
  • Patients’ empowerment and engagement in their care (some of which may be a cultural stretch
  • Specific commitment of the participants to follow the management/direction of the network to ensure a full and active participation, meeting objectives and commitment to continuous quality improvement by physicians, nurses, and support staff at every level
  • Marketing and public relations to let people know of the existence of the reference network and its offer and capabilities.

However, one can structure framework policies, framework procedures, and framework laws. Unfortunately, if one doesn’t fill in the reticular web that connects the details, processes, operational policies, procedures, forms, and other tools, standards, and protocols, things fall through cracks. This is because most frameworks are merely outlines that lack enough substance to get to the next level, operationally.

Whether in Europe, Asia, the Middle East, or Latin America and the Caribbean, to take medical tourism to the next level will require a huge, original effort on the part of all the participants and government authorities. There are no existing, publicly available template documents, model forms, or model policies and procedures to download from the Internet.  There are privately held, proprietary document sets that can be used to fast track a network, but each network will be culturally and geographically unique with assets unlike any other network.  The right designer will be able to leverage those unique assets, adapt to the culture and network objectives and build the network much like an architect incorporates common accepted design principles and builds a foundation, four walls and a rook and ultimately creates from these basics a lavish palace or a modest country cottage each of which provides shelter from the elements.