Facing economic uncertainty that taxes ones sense of well-being, patients are increasingly looking to take control of their health and actively participate in making smart, safe, cost-effective healthcare decisions. At the same time, the landscape of healthcare is changing, enabling them to play a greater role in doing so.
It’s becoming an information rich global marketplace in which everyone gets to play. To borrow from the title of Thomas Friedman’s book, “The World is Flat,” or more accurately, “flattening.”
INTRODUCTION
Never before have the pressures and opportunities been greater for patients to get smart about their healthcare decisions.
According to data from the Commonwealth Fund (www.commonwealthfund.org/Content/Publications/In-the- Literature/2008/Jun/How-Many-Are-Underinsured–Trends- Among-U-S–Adults–2003-and-2007.aspx) in 2007 more than 50 million adults in the United States are uninsured, and another 25 million have inadequate medical insurance.
More than one half of the underinsured and about two thirds of the uninsured went without needed medical care and approximately 50% had difficulty paying their bills. In fact, half of all bankruptcies in the United States are related to the difficulty of paying healthcare bills.
Now, we are also in the midst of the worst economic downturn since the Great Depression, with rising unemployment further threatening insurance coverage. And even if one is fortunate enough to maintain coverage, benefits have been constricting due to rising cost pressures.
In healthcare, flattening is occurring in two major arenas to empower patients to more fully participate in their healthcare decisions and broaden the horizons within which they can implement them.
Flattening Of Medical Decision Making
A couple of decades ago decisions in medicine were largely driven by the expert opinion of doctors. The weight and influence of these decisions were stratified by the hierarchy and stature of the medical expert. Without independent access to medical information or knowledge on how to process it, patients could not fully participate in these decisions.
In 1992, the launch of Evidence-Based Medicine (EBM) created a major paradigm shift to usurp this reliance on expert opinion, enabling all stakeholders including patients and their family members to participate in decisions around health care.
Hailed by the British Medical Journal as one of the top 15 medical advances (http://www.bmj.com/cgi/content/full/334/ suppl_1/DC3) since 1840, EBM provides a framework that places scientific evidence at the foundation of clinical decision making. With increasing access to scientific information on the Internet in the late 1990’s the movement took off and now serves as the standard by which healthcare providers make medical decisions.
The Internet has also opened the world of scientific information to patients, who have responded to this access in droves. In 2006, the Pew Survey (http://www.pewinternet.org/Reports/2006/ Online-Health-Search-2006.aspx) estimated the numbers of adults searching for online information at 113 million in the U.S. alone.
In 2007, more patients turned to the Internet for health information than to their doctors. At the same time there has been a rush to satisfy this hunger for the consumption of online health information. New ‘portals’ and web-based health search engines have been forming in record numbers.
As patients, often with the support of family members or friends, begin to combine this readily available access to information with an understanding of the basic concepts of EBM a more level playing field emerges on which they are more fully empowered to actively engage in decisions with their healthcare providers.
Flattening of Healthcare Delivery in a Global Marketplace
One of the most significant recent developments in healthcare has been the rise of medical tourism that has been facilitated by a flattening of access to the global marketplace. The globalization of healthcare echoes a transformation that has been seen across a broad range of other industries which has been driven by several influences including technology facilitating global communication and access to information; outsourcing; global supply chains; and political factors leading to the opening of markets in several regions including Russia, China, India, Southeast Asia, the Middle East and Latin America.
The globalization of healthcare is being shaped by a number of other factors including the commoditization of international biomarkets that have expanded to a 410 billion dollar industry, a rising middle class including countries such as India, Indonesia and China that are becoming increasingly mobile and demanding of quality medical services, and the emergence companies and organizations whose objective is to facilitate and deliver patients to hospitals, health systems, dental clinics and health and wellness retreats in the international marketplace. Key relationships are developing between medical tourism organizations, patients, payers, providers, and facilitators to support medical travel abroad.
As these trends flatten the barriers to seeking healthcare abroad, a mass migration is taking place. According to a report by Deloitte on Medical Tourism, (http://www2.deloitte.com/assets/Dcom-UnitedStates/Local%20Assets/Documents/us_chs_MedicalTourismStudy(1).pdf) an estimated 750,000 Americans traveled to other countries for medical care in 2007. This number is estimated to increase by an annual growth rate of 100% per year to six million in 2010. The US market alone for outbound medical tourism is anticipated to be approximately $60 billion.
This flattening landscape is yielding fertile soil to support the Rise of the Smart Patient in the Global Health Market. To get smart, actively engage in healthcare decisions and take full advantage of the opportunities the global marketplace has to offer, patients need to cultivate key capabilities to sort though and absorb the readily accessible information and seek and implement safe, quality and affordable healthcare wherever it may be available.
THE SIGNATURE OF SMART PATIENTS
The Smart Patient assumes the role of “CEO of their health” and are empowered to share in decisions around their care with skills to:
• Identify what works
• Navigate the global health system to implement what works
This article will primarily focus on the capability to identify what works.
Harnessing Evidence-Based Medicine to Identify What WorksPatients can more clearly identify what works and participate in their healthcare decisions by learning the core concepts of EBM, the same skills their healthcare providers use to navigate scientific evidence. EBM involves 4 key components enabling one to:
1) Frame questions properly
2) Find the best available evidence using the Internet to answer questions
3) Evaluate the evidence to ensure it’s relevant and reliable
4) Apply the evidence to healthcare decisions
A thorough review of each of these steps is available through the Evidence-Based Medicine Resource Center (www.supersmarthealth.com/ebm) at SuperSmartHealth.com, a free resource that teaches healthcare providers and patients the basics of EBM. To summarize:
STEP 1 ~ FRAMING QUESTIONS
It’s not sufficient to simply inquire whether a particular intervention works. Unless you frame the question well, you risk getting the right answer to the wrong question. A well framed question includes 4 components:
1) Patient Population
2) Intervention
3) Comparison intervention
4) Outcomes
Known by the mnemonic PICO, this format reminds one to consider whether the patient population
(P) of any research being sought indeed reflects the individual patient it is being considered for; the intervention
(I) is available to that patient; the benefit of a particular therapy is not simply being evaluated against a placebo (unless doing nothing is the standard of care), but is compared
(C) against the current best available regimen; and that the outcomes
(O) of benefit demonstrated in the research are truly meaningful to the patient’s quality and length of life, rather than simply a change in some laboratory test value.
An example of a well framed question would be, “For patients with debilitating hip osteoarthritis how does a total hip replacement compare with hip resurfacing with respect to reduction in pain, return to normal activity, and surgical complication and revision rates?
Formatting the question in such a way increases the likelihood the right answers to the right questions will be found when one proceeds to search for information on the internet.
STEP 2 ~ FINDING THE EVIDENCE
After questions are framed appropriately, one next searches for the best available scientific information to answer them.
According to the Pew Online Health Search Survey (2006) 66% of individuals begin their health inquiry at a search engine like google.com. This typically returns an overwhelming amount of information, although Google now enables one to refine the search by categories such as, treatment, test/diagnosis, symptoms, causes/risk factors and alternative medicine.
Another 27% start at a health related website. The top trafficked websites as of November 5th, 2009 according to ebizmba (www.ebizmba.com/articles/health-websites) are:
1) WebMD.com
2) NIH.gov
3) MedicineNet.com
4) MayoClinic.com
5) Drugs.com
The quality of these top ranked websites has improved dramatically over the years and they may be a reasonable, systematic place to start. The top nonprofit health site, NIH.gov, the medical research agency for the United States, acts as a clearinghouse for the 27 institutes and centers that make up the NIH. It provides access to a comprehensive A-Z list of health topics, as well as newsletters, and a helpful list of toll-free hotlines to a broad range of health organizations.
Beyond the websites ranked most popular, are other quality resources too numerous to mention in the space of this article. However you can find links to many of them through The Consumer and Patient Health Information Section (CAPHIS) of the Medical Library Association’s “Top 100 List” of “Health Websites You Can Trust” at http://caphis.mlanet.org/consumer/generalhealth.html.
One resource worth mentioning on the CAPHIS list is MedlinePlus.gov, the consumer portal of the U.S. National Library of Medicine. It is one of the best patient education resources you will find with extensive information on approximately 800 health-related topics, the latest health news, a comprehensive resource on drugs and complementary alternative medicine supplements, an illustrated medical encyclopedia, interactive patient tutorials, a medical dictionary, an extensive list of organizations by health topic (http://www.nlm.nih.gov/medlineplus/organizations/orgbytopic_a.html), which have been pre-screened for quality, authority and accuracy of health content. This enables a patient to efficiently identify the top few websites related to their particular health condition.
Another resource listed is the Center for Disease Control and Prevention website, CDC.gov. It has an excellent section on Travelers’ Health that helps guide one on disease considerations and requirements with travel to various destinations.
A few other resources referenced by CAPHIS also bear mention: Healthfinder.gov developed by the Department of Health and Human Services, MayoClinic.com (one of the top 5 most popular sites above), ClevelandClinic.org, and FamilyDoctor.org produced by the American Academy of Family Physicians.
The strong point of many of the resources listed above is that they cater to the health literacy of the “average” internet user and satisfy their expectations for the quality and quantity of relevant and reliable information. For select patients with high health literacy (or for their designated “EBM champions” who search on their behalf), the following 3-step drill down strategy may also be offered as an efficient and rigorous way to find high quality evidence-based information.
First, these patients may begin searching the same online medical textbooks healthcare providers search, such as those at eMedicine.com and UpToDate.com. Many chapters of both resources provide links to free consumer information. The health professional information of UpToDate requires a subscription, but motivated patients may pay $20/week or $45/month for full access.
Next, patients can drill down further looking for high quality evidence-based information on focused clinical questions in the form of systematic reviews or practice guidelines. The Cochrane Collaboration (http://www3.interscience.wiley.com/ cgi-bin/mrwhome/106568753/HOME) publishes some of the highest quality reviews around and provides free abstracts with easy to read plain language summaries for patients.
The National Guidelines Clearinghouse (NGC) (guidelines.gov), is the single best resource to find practice guidelines from hundreds of institutions and affiliated organizations. Links are provided to the major recommendations and, where available, to the full-text of each guideline and handouts for patients.
Finally, patients who want to drill down even further to search for the latest studies on their specific questions of interest can search the U.S. National Library of Medicine’s MEDLINE database at Pubmed.gov. PubMed currently searches over 19 million records from approximately 5000 journals.
A helpful tutorial is available to guide individuals in using its powerful search tools, including the “Clinical Queries” link that has filters for searching on questions of therapy, diagnosis, etiology and prognosis. Abstracts can be downloaded for most articles and some have links to free full text articles. For those that don’t, one can try retrieving the full text article through freemedicaljournals.com, which provides free access to almost 1400 journals.
When traveling it can also be helpful to search the website of the particular provider or institution offering care under consideration with the caveat that it is also important to thoroughly evaluate what you find to ensure the information is reliable. A number of websites such as medicaltourism.com and allmedicaltourism.com offer directories to healthcare providers and the websites and services they offer.
STEP 3 ~ EVALUATING THE EVIDENCE
According to the Pew survey, almost three quarters of health seekers do not consistently check the sources and date of the health information they find online. It’s essential to evaluate the reliability of information online.
There are two key steps to evaluating information online: first, evaluate the reliability of the website searched and second, evaluate the quality of the research that the website ideally references.
MedlinePlus has a helpful section on “Evaluating Health Information Online” at www.nlm.nih.gov/medlineplus/evaluatinghealthinformation.html. It leads off with a flash tutorial at www.nlm.nih.gov/medlineplus/webeval/webeval.html which goes through four key considerations, including who authored and funded the site, how to determine quality, and issues of privacy.
The big issue for patients evaluating the quality of research referenced on websites involves the ability to recognize recognizing a hierarchy of evidence: how randomized controlled trials (and systematic reviews they contribute to) tend to provide more reliable information than observational studies, which provides superior information to anecdotal evidence.
You can find more information on this and on how to tell whether evidence is relevant, believable, and meaningful at the Evaluate the Evidence section of the Evidence-Based Medicine Resource Center at SuperSmartHealth.com.
STEP 4 ~ APPLYING THE EVIDENCE
This step involves a consideration of all the options, extrapolating from the evidence the likelihood of the key outcomes for each option and weighing the patients’ preferences for those outcomes.
In deciding whether any one approach is a step better than another, physicians and patients may weigh all the outcomes to consider using the mnemonic STEPC.
• Safety: Here one considers serious life threatening complications by searching the best available research reporting complication rates for the intervention or diagnostic test and by soliciting the specific complication rates in the hands of the particular practitioners and institutions delivering the care under consideration. Unfortunately safety information on specific institutions may not always be available. An important surrogate to provide some reassurance on safety is to look at whether the facility has been accredited based on a formal review of their safety and quality practices. Some of the most important organizations that work on accrediting institutions include The International Society for Quality in Healthcare (ISQua), who also accredits other accrediting organizations such as the Joint Commission International (USA), The Australian Council on Healthcare Standards, Accreditation Canada, CHKS Healthcare Accreditation Quality Unit (UK), and others (see www.isqua.org/IAP-Awards.htm).
• Tolerability: This relates to the general discomfort of the particular intervention or diagnostic test.
• Efficacy: The approach is similar to the consideration of safety above. One looks for the best available research on outcomes of efficacy that would be truly meaningful to the patient and by also soliciting the specific success rates in the hands of the particular practitioners and institutions delivering the care being considered. Here too it’s important to ensure the facility has accredited based on a review of their quality practices.
• Price: The cost savings of medical travel can be considerable. According to a report by Deloitte on Medical Tourism, even when extraordinary travel and insurance costs are added in, the relative cost advantage of having a procedure performed outside the USA ranges from 28% to 88% depending on the location and procedure. Websites such as medicaltourism.com and allmedicaltourism.com provide information that enable you to compare costs on specific procedures between countries. In addition, a helpful World Budget Estimator is available at http://health.usnews.com/articles/health/special-reports/2008/05/01/world-budget-estimator.html. It enables you to tabulate all travel and treatment-related costs at facilities abroad and compare this to the costs of treatment at facilities in the USA.
• Convenience: This refers to the relative convenience of having one procedure over another. When it comes to medical tourism this also includes the convenience and comfort of travel, gaining visa entry into particular countries, and post-op recovery in a foreign country.
In addition to weighing the outcomes of an intervention using the mnemonic, STEPC, their may be a number of potential advantages when considering the possibility of medical travel. These can be remembered by the 5A’s:
• Access: Some procedures may not be available in the USA. For procedures that have not been FDA approved, close scrutiny, particularly around the outcomes of safety and efficacy is key.
Availability: Some countries have waiting lists for having certain procedures that are more readily available in others.
• Anonymity: Some patients value their privacy around certain procedures and welcome the anonymity that comes with travel.
• Amiability: Many foreign destinations pay particular focus on extending hospitality and compassionate care and may be able to accommodate a lower ratio of nursing attendants to patients than found at American facilities. Some facilities have service levels that resembling 5 star hotels. In addition, for many Diaspora populations, getting healthcare in countries of origin may feel more comfortable and familiar. Many have ties to these countries via extended family members and friends who are knowledgeable about the hospitals, physicians, and the local healthcare industry.
• Adventure: Minor cosmetic surgery and a trip to the Himalayas or perhaps a safari in South Africa…sound tempting?
In addition to these advantages of travel some patients may also consider one more “A” as a potential disadvantage of medical tourism:
• Adjudication: Some patients may consider the challenges in seeking a legal remedy should they receive negligent care at a particular foreign destination before they decide to undertake the trip.
The way medical tourists weigh these abovementioned considerations are a function of personal preferences, which are usually affected by the type of care they are seeking and their main reasons for travel to begin with.
Patients may travel for needed major or minor surgeries, diagnostic services, integrative medicine treatments, rejuvenation and wellness, or dental or cosmetic procedures. Those who travel for necessary major surgeries will likely pay close attention to the Safety and Efficacy of care and quality of post op recovery.
Patients who travel for rejuvenation and wellness will likely pay relatively greater attention to Amiability and Adventure. For patients who are traveling because they are uninsured or underinsured and have financial hardships, Price will be a strong driver.
Once the patient has thought through the intervention and feels comfortable they have done their due diligence to know what (and where) will likely work best, they are one giant step closer to packing their bags. The next skill they need is the know how to navigate the landscape they are entering so they can effectively implement what they’ve assessed will likely work.
Navigating the Global Health System to Implement What Works
Smart Patients can expand their horizons and learn to become skilled “medical tourists”. The American Medical Association’s Guidelines on Medical Tourism can be a good place to start to anticipate key issues to consider. The AMA guidelines seek to protect the interest of patients, by advocating that employers, insurance companies, and other entities that facilitate or incentivize medical care outside the U.S. adhere to the following principles (which may be extrapolated to outbound patients from other countries too):
(a) Medical care outside of the U.S. must be voluntary.
(b) Financial incentives to travel outside the U.S. for medical care should not inappropriately limit the diagnostic and therapeutic alternatives that are offered to patients, or restrict treatment or referral options.
(c) Patients should only be referred for medical care to institutions that have been accredited by recognized international accrediting bodies (e.g., the Joint Commission International or the International Society for Quality in Health Care).
(d) Prior to travel, local follow-up care should be coordinated and financing should be arranged to ensure continuity of care when patients return from medical care outside the US.
(e) Coverage for travel outside the U.S. for medical care must include the costs of necessary follow-up care upon return to the U.S.
(f) Patients should be informed of their rights and legal recourse prior to agreeing to travel outside the U.S. for medical care.
(g) Access to physician licensing and outcome data, as well as facility accreditation and outcomes data, should be arranged for patients seeking medical care outside the U.S.
(h) The transfer of patient medical records to and from facilities outside the U.S. should be consistent with HIPAA guidelines.
(i) Patients choosing to travel outside the U.S. for medical care should be provided with information about the potential risks of combining surgical procedures with long flights and vacation activities.
Navigating outbound travel for healthcare can be a challenging task and difficult to accomplish on one’s own. The smart patient may become smarter more quickly by co-coordinating their outbound care with the assistance of highly experienced and preferably certified medical tourism facilitators whose functions ideally include:
• Provide patient with a list of Medical Tourism Destinations and Providers for their requested medical treatment
• Review the package options including travel arrangements, desired accommodations and tourism
• Review pricing options for the desired package
• Assist in transferring medical records
• Facilitate communication between the local attending physician and the physician in the destination of choice in order to ensure proper pre and post operative care
The Medical Tourism Association, a non-profit trade association, provides Medical Tourism Association Facilitator Certification to set standards for delivery of this service that satisfy the abovementioned functions and more. A checklist of questions asked of facilitators applying for certification is available on the Medical Tourism Association website. (http://www.medicaltourismassociation.com/certification.html)
For a little more review of what to look for in a medical tourism facilitator, you can read more through Medical Tourism Magazine, the official publication of the Medical Tourism Association.
http://medicaltourismmag.com/detail.php?Req=283&issue=13 or http://medicaltourismmag.com/detail.php?Req=146&issue=7. You may also read about other patient’s experiences at http://medicaltourismmag.com
SUMMARY AND CONCLUSION
Skills are attainable to support patients becoming smarter in the way the make decisions about seeking care in the global marketplace. In addition to learning how to navigate the landscape of outbound care, Evidence-Based Medicine provides patients and healthcare providers the foundation for making smart healthcare decisions. While this article focused on the patient, a future article will be dedicated to supporting health care providers with a practical approach to incorporating Evidence-Based Medicine into their clinical practices and illuminate how Evidence-Based Medicine sets the foundation for the goal of delivering of safe and quality care in the global marketplace.
Daniel Friedland, MD is the Founder & CEO of SuperSmartHealth (www.supersmarthealth.com), which is dedicated to teaching Evidence-Based Medicine to healthcare providers, allied healthcare professionals and patients. He is the author of Evidence-Based Medicine: A Framework for Clinical Practice, one of the early textbooks on the topic. Over the past ten years Dr. Friedland has consulted and provided hundreds of training programs on EBM for physicians, allied professionals and patients throughout the United States. Now he is bringing his EBM consultation and training programs to the global community. Dr. Friedland can be contacted at daniel@supersmarthealth.com
Renée-Marie Stephano is the President of the Medical Tourism Association. Ms. Stephano is also the Editor of the Medical Tourism Magazine. Having a background in international marketing and relations, health law and litigation, she provides a valuable service to the Medical Tourism Association in these fields. Renée-Marie is licensed to practice law in the State of Florida, in the Commonwealth of Pennsylvania and in the State of New Jersey. Ms. Stephano speaks regularly at international conferences on the Legal Issues Surrounding Medical Tourism and in the United States to employer groups, insurance groups and physician associations. Renée-Marie consults international government ministries, private sector organizations and NGO’s about the growth of the global healthcare industry and accreditation, providing marketing assistance to promote their countries high quality of care. She may be reached at Renee@MedicalTourismAssociation.com
Vivian Ho is President of AGHP, a 501c3 that works on global health philanthropy ventures. She also serves as Managing Director, Asia Pacific for MTA, and Co-Editor of MTA’s health tourism e-magazine. Prior to this, Vivian was President & CEO of Queens International in Honolulu, Hawaii building Hawaii’s medical travel & health tourism initiative. She currently advises on country, sector and organization initiatives in Medical & Health Tourism. She may be reached at Vivian@MedicalTourismAssociation.com
