AMA-OMSS JUNE 2007

Report B: Medical Travel Outside the U.S.

OMSS Action: Adopted recommendations of Governing Council Report B with a change in title, and filed the remainder of the report.

HOD Action: Referred Resolution 732.

Introduction

At its 2006 Interim Meeting, the American Medical Association (AMA-OMSS) Assembly referred OMSS Resolution 6, "Medical Tourism and Quality Care," along with the Heartland Caucus amendment. Referred Resolution 6 and the amendment asked that our AMA:

1. Study the trend of "outsourcing" health care overseas in order to better understand the magnitude of the practice and its impact on U.S.-based physicians having to "pick up" the pieces after a procedure is done overseas without follow-up care by the overseas provider. 
2. Work to encourage any health insurer using physicians in foreign countries to guarantee that reasonable U.S.-based follow-up care will be available prior to sending the patients to a foreign country.
3. Advocate that any health insurer sending patients to foreign countries require credentialing and assessment of the physicians in foreign countries and facilities comparable to that required for providers and facilities in the U.S.
4. Work to assure that all patients have the option of U.S.-based health care if they so choose.
5. Work to assure that patients sent overseas by their health insurer for medical procedures are provided with the same appeal and legal rights as to their benefits as they would be provided were their provider U.S.-based.

This report discusses the reasons why Americans are traveling the world for health care, provides an industry overview, and offers conclusions and policy recommendations.

1. OVERVIEW

In 2005, an estimated 500,000 Americans journeyed overseas for medical care, often as part of a vacation-like travel packagei. Medical tourism is now a world-wide, multibillion dollar phenomenon that is expected to surge in the coming years along with the ranks of cost-conscious uninsured Americans and financially strained U.S. employers.

In the past, those that traveled internationally for healthcare were typically interested in treatments that were either unavailable in their home country or were not covered by health insurance (including many cosmetic and dental surgeries). However, due to increased out of pocket healthcare expenses in America, along with long waiting lists in single-payer countries like the U.K. and New Zealand, many westerners are now traveling to developing countries like India, Thailand, and the Philippines for procedures like heart surgery, knee replacements, and hip resurfacing. OMSS Governing Council Report B – Page 2

Travel agencies and insurance companies catering to the medical tourist have sprung up around the nation and the world, often touting the fact that the hospitals they send their clients to are accredited by the Joint Commission International and that the physicians the patient will see, who are sometimes introduced to them via teleconference, have been trained in the U.S. or have U.S. Board Certifications.

It is possible that the effects of medical tourism could soon be felt by the grassroots physician. When combined with recent domestic initiatives for transparency in healthcare price and quality (including President Bush’s 2006 Executive Order on the matter), the fact that major payers and employers may soon follow in the footsteps of individuals and self-insured firms now leading the charge overseas could exert significant downward pressure on U.S. fees in the coming decades, driving down physician reimbursements and making it more difficult for doctors and hospitals to cross-subsidize patient careii. To illustrate, the international price gap for a mitral valve replacement operation can be over $150,000; the procedure in India might cost $9,000, whereas in the U.S. the price is closer to $160,000iii (see Appendix A). The financial benefits to an uninsured individual are clear, and given the large and growing costs U.S. employers pay for their workers’ health care, it is easy to see why American firms might be interested in tiered insurance plans that could serve to narrow the international price gap by including providers in foreign countries. Mercer, a major human resources consulting firm, is currently developing such programs for several Fortune 500 companiesiv to allow them to outsource elective surgeries, and the West Virginia State Legislature is considering a plan to cover State employees for treatment outside the U.S., including first class flights for the patient and a companion, recovery in a four-star hotel, and other incentives including bonuses and sick leavev.

Due to the potential impact of medical tourism on patient safety and on the profession of medicine, the trend is clearly an issue that the AMA should be monitoring closely. This report provides context for evaluating the medical tourism business by exploring the reasons behind a U.S. patient’s decision to seek medical care in a foreign country, summarizing the current state of the industry, and discussing the global convergence of medicine. Because participation by major insurers would appear to be the tipping point, it is recommended that the AMA-OMSS Assembly focus on this aspect of the medical tourism industry when formulating a resolution to present to the AMA House of Delegates at the 2007 Annual Meeting. Policy opportunities in this area might include developing model legislation to regulate U.S.-based travel agencies and insurance companies seeking to send American patients overseas for medical care.

2. DISCUSSION

2.1. Why Americans Travel the World for Health Care

America’s healthcare system has failed many of our citizens, in particular the 46 million uninsured. While some are willing to wait until their symptoms are acute enough to warrant an emergency room visit (when their condition will be most difficult to address and their care will be the most expensive and least effective), those that seek to take preventative action can either search for health coverage (which is often cost-prohibitive in the light of serious pre-existing conditions) or face self-pay charges arbitrarily set by hospital CFOs.

At a June, 2006 hearing held by the U.S. Senate Special Committee on Aging, "The Globalization of Healthcare: Can Medical Tourism Help Reduce Health Care Costs?",

OMSS Governing Council Report B – Page 3

Senator Gordon Smith (OR) observed that while Americans should not have to travel overseas for affordable health care, the decision to do so has become an understandably attractive option for the nation’s uninsured. The following section describes how market forces including 1) price sensitivity, 2) competition on quality, 3) customer service, and 4) convenience may accelerate growth in the medical tourism movement in the coming years.

2. Price sensitivity. The expense of standard medical treatment is forcing uninsured patients to seek healthcare outside the scope of traditional medicine through the use of complementary and alternative healthcare, by making visits to retail health clinics, and increasingly by looking to physicians in foreign countries when they find that they have run out of local options. But it is not only uninsured individuals that are looking overseas. As the weight of providing healthcare cuts into profits and impairs the ability of both small and large employers to compete in the global market, some American companies are looking for international solutions to help them stay afloat until they can get out of the healthcare businessvi. To that end, self-insured firms have begun to explore the possibility of providing voluntary medical travel options to workers. Prices offered to medical tourists are often 60-85% lower than insurer-negotiated charges in the US, a margin that easily offsets travel, first class hotel for the patient and a companion, and often an opportunity for the patient to share in the financial savings enjoyed by the employervii. In short, price sensitive consumers may consider America less competitive as medicine goes global. Along with our higher labor and malpractice insurance costs, drug, device, and equipment manufacturers currently have differing price schedules across countries. How quickly international competition will flatten these differentials remains to be seen, but it is doubtful that parity in those factors alone will close the international price gap. Given that the Institute of Medicine has estimated that 30-40% of all American healthcare spending is waste, we will continue to fall short in international benchmarks of value until major public and private payers create a profoundly more efficient system that is sensitive not only to price, but also to qualityviii.
   
3. Competition on quality. Does cheaper necessarily mean lower quality? Is traveling overseas for a common procedure truly a danger or are objections from organizations like the Society of Plastic Surgeons merely protectionist scare tactics? The Joint Commission International (JCI) has accredited over 100 foreign facilities, but given the significant differences between the Joint Commission’s domestic and international standards (see Appendix B) does that mean that the quality of care in those hospitals is truly comparable to what one would expect in the U.S.? Should those that want to ensure quality patient care focus on transparency in outcomes data on or on compliance with JCI Standards?

   Answering these questions will become easier each year as more and more outcomes data is made public both domestically and internationally. In 2006, President Bush signed an Executive Order directing Federal agencies to promote price and quality transparency in healthcare through the collaborative development of quality measures, the aggregation of claims data, the procurement of interoperable information technology, and the adoption of pay-for-performance models of reimbursement by January 1, 2007. Accordingly, the Center for Medicare and Medicaid Services (CMS) has begun posting the prices it pays physicians for certain services online, along with the number of services provided in each Medicare locality (a figure that might correlate with more experience and therefore higher quality). Although private payers are not required to make their pricing schedules public, CMS contends that Medicare patients might "get a better deal on care if they are OMSS Governing Council Report B – Page 4

   willing and able to travel elsewhere in the state to receive it"ix, translating into lower costs for the patient and for CMS. CMS also asserts that the uninsured will be able to make good use of the information when negotiating with doctors and hospitals about fees. Additional quality measures are also being posted to the web. For example, it is expected that by June, 2007, the 30-day mortality rates of heart failure and heart attack patients will be posted to www.hospitalcompare.hhs.gov, by hospital, using methods developed at Harvard and Yale and approved by the National Quality Forum. "We are supporting collaborative efforts that are providing unprecedented information to help people get the best quality care for the best price," said CMS Acting Administrator Leslie Norwalk.

   The data is beginning to show tremendous variation within and across states, but how do performance measures compare across countries? Patients may soon be able to answer that question as hospital standardized mortality ratios (HSMRs) become more public (the HSMRs for 29 hospitals in Minnesota were published on a Web site in 2005) and international competition across specialty hospitals brings quality differences to light.

   For example, with respect to inguinal hernias, "it is less expensive to fly someone round-trip from Boston to the Shouldice Hospital for three days and pay the entire bill than to have the procedure done locally. Furthermore patients recuperate and return to work much faster because of the nature of Shouldice procedures"x. Shouldice (www.shouldice.com) is a specialty hospital in Ontario that has the lowest inguinal hernia recurrence rates in the world. Maple Leaf HIFU (www.hifu.ca), a Canadian prostate cancer specialty hospital, has also attracted a number of Americans since it first started treating patients using the non-invasive Ablatherm HIFU device in April, 2005. The for-profit facility treats a total of 25 patients a month for the $21,500 treatment that is not yet available in the United States. On the other side of the globe, several Indian hospitals, including Escorts Heart Institute and Research Centre (www.ehirc.com), are working hard to be recognized as global centers of excellence in heart surgery.

   The fact that large payers are looking to outsource elective surgeries would not be possible without the recent perceived increases in quality at international hospitals. As has happened in the automobile industry, it is conceivable that in the future, Americans will chose international providers of medical care not only for cost reasons, but also on the basis of side-by-side quality comparisons. According to Ann Mond Johnson, President of Subimo, LLC:

   "We’re going to see more risk- and severity- adjusted data provided by overseas providers as they position themselves to compete against American providers. An Orbitz or Expedia for healthcare…is a real possibility…and we’ll see the importance of the brand continue to grow…this is a natural development of Americans becoming savvier healthcare shoppers…when Americans realized more LASIK was being done in Toronto at a lower price, they began heading north for that procedure. What is different now is that as our financial exposure grows, we’re more inclined to shop for and create our own value equations for a broader spectrum of health servicesxi." OMSS Governing Council Report B – Page 5
   
   Customer service. Physicians are often so pressed for time in the U.S. that a patient may spend only a few moments with them prior to having a procedure. Frustration with a perceived lack of courtesy may also contribute to the medical tourism trend, particularly since many patients do not have a close relationship with their health-plan assigned physician nowadays, and because the demands on American nurses are often stretched beyond appropriate working conditions. The CEO of IndUSHealth has stated that his affiliated doctors and nurses are very aware of the impact that customer service will have on their hospital’s "brand" and are very much geared toward ensuring that their patients are treated well and are satisfied. Finally, some assert that falling cultural barriers resulting from the fact that 25% of physicians practicing in the U.S. are international medical school graduates may mean that Americans will feel less apprehension about working with foreign doctors in the future than they may have felt in the pastxii.
4. 
   Convenience. For patients from the United Kingdom, New Zealand, or other countries with long waiting lines for some healthcare services, traveling overseas can allow them to get treatment sooner. For Americans, the one-stop-shopping offered by a number of medical tourism companies, including making all arrangements for the patient’s flight and accommodations and assigning U.S.- and destination-based "program managers", may be a draw, along with the leisure and anonymity medical tourism companies promise during the patient’s recuperation.
   
5. Legal landscape. Uninsured patients will probably have little legal recourse, and the insured are only slightly less likely to encounter serious difficulties in seeking legal remedies for bad healthcare outcomes incurred overseas. Medical tourism is a new and evolving area of the law; many issues vary across states, and legal theories such as "vicarious medical malpractice liability", for example, have yet to take root in court. That said, it is probable that in most areas of this developing industry the medical tourism company (MTC) will act as a third party administrator for the patient's insurance company.

6. The MTC will likely use a disclaimer in its contract with the insurance company, disclaiming liability for any wrongdoing in connection with the referral process or for care rendered by the overseas patient care providers. Whether that disclaimer is upheld will likely be a state specific determination. The US patient can always sue the MTC in the state in which the patient resides or in which the insurance contract is written. However, whether a cause of action is recognized for negligence in the process of referring the patient to the overseas provider, will again be a state specific determination.

   Like the MTC, the insurance company is likely to have a disclaimer for tort liability related to the care rendered overseas. Of course, the patient could sue the insurance company in the state in which the insurance contract was entered into, and the insurance company may be liable either in contract or for negligence in the referral process, depending on the state.

   On the issue of enforcement, collecting a judgment against the insurance company would likely be less problematic than collecting against the MTC, since the insurance company is likely to have assets in the US. If the MTC does not have assets in the USA, collection on a judgment would require legal action in the foreign country. OMSS Governing Council Report B – Page 6

   2.2. Market Overview: Countries, Travel Agencies, and Insurance Firms

   The U.S. is a net importer of patients, but in the last five years a significant and growing number of Americans have traveled to other countries for high quality, lower cost health care. Their trips are facilitated by foreign governments, entrepreneurial travel agencies, and insurance firms.

   Selected Countries:
   

7. Mexico is a popular destination for Americans, and physicians, dentists, and private hospital companies are building new facilities along the border to attract patients within driving distance. Cross-border health insurance plans have enrolled more than 150,000 Californians.
   

8. India attracts about 150,000 patients each year; its facilities are known for heart surgery and hip resurfacing. English-speaking physicians and nurses put American patients, many of whom are accustomed to Indian doctors (there are 37,000 practicing in the US) at ease. The Indian government recently introduced a new category of visa: the M-Visa, or Medical Visa, to be issued to medical tourists. The government has also initiated an initiative on uniform pricing for several specialty servicesxiii, and defines the treatment of foreign patients as an export, making such treatment "eligible for all fiscal incentives extended to export earningsxiv".
   

9. Malaysia’s private hospital groups started targeting medical tourists in the late 1990s with the help of the Malaysian government. Prices are up to 80% less than prices in the U.S.
   

10. Thailand is home to perhaps the world’s most famous medical tourism destination: Bumrungrad International Hospital, which treated 55,000 Americans last year.
    

11. The Philippines competes with Thailand for western patients; its government began actively promoting medical tourism in 2006. Many of the country’s doctors, surgeons and dentists were educated in Europe and the United States. The Department of Health estimates that 250,000 people visited the Philippines in 2006 for eye treatment, cosmetic surgery, and dental treatment; it expects that the industry will draw between $300-$400 million in 2007xv.
    

12. South Africa attracts more than 100,000 medical tourists from around the world each year; its high-quality academic medical centers and English-speaking physicians and nurses make it a preferred destination for many British patients.
    

13. Brazil and Argentina have attracted cosmetic surgery patients from around the world for decades, and new medical facilities, along with favorable exchange rates, are positioning them to compete for medical tourists in other areas as well. Brazil has the most Joint Commission accredited hospitals of any country outside the U.S.
    

14. Costa Rica is a popular destination for plastic surgery and dentistry, and was the first country to offer "recovery retreats" for the post-surgical period.

2. GlobalChoice Healthcare (Albuquerque, NM) states: "Our company was established with the goal of opening access to worldwide healthcare facilities to corporate America. We contract with domestic and international healthcare facilities capable of delivering the highest quality healthcare on a fixed-price, all-inclusive basis. These savings are in turn passed through to insurers who can represent them to their clients. We provide all of the logistics and travel arrangements to enable individuals to take advantage of this expanded network. This service includes the qualification of the client for medical travel, HIPAA compliant electronic transfer of medical records, scheduling of procedures, procurement of travel documents when needed, arrangement of travel and accommodations, client assistance at the international destinations, and client transport at the site of care. The GlobalChoice Healthcare Benefit is a complete, packaged solution for companies wanting to take advantage of global medical carexvi".
   
3. IndUSHealth (Raleigh, NC) states: "At IndUShealth, we offer an affordable, high-quality global health care option. By partnering with India's leading hospitals – Apollo, Escorts and Wockhardt – we provide easy access to some of the best care in the world, at a fraction of U.S. costsxvii".
   

4. MedRetreat (Vernon Hills, IL) is launching a division to market services to employers beginning in 2007xviii, its mission statement is as follows: "Our mission at MedRetreat is simple. We want to help you receive your medical procedure at the best and most reputable healthcare facilities the world has to offer, and, design an exotic and amazing recuperation experience; all at a fraction of the cost in the USxix".
   

5. ."
   
   . Health plans certainly have a financial incentive to export patients. The tipping point in the medical tourism trend will likely occur when major insurance plans begin incentivizing patients that are willing to go overseas for care.
   
   In March, 2007, BlueCross BlueShield of South Carolina began to cover surgeries at Thailand’s Bumrungrad to members whose policies do not cover the surgery they need.
   
   BlueShield of California offers plans to individuals who permit members to receive their health care in Mexico or Southern California.
   
   OMSS Governing Council Report B – Page 8
   
   United Group Programs (UGP) of Boca Raton, FL caters to self-insured employers and has begun promoting overseas surgeries to 40 corporations.
   
   2.3. The Global Convergence of Medicine
   
   Frustration with US health care costs, specialization and improving quality overseas, and the ease of international travel (tourism is expected to triple by 2020), are encouraging more people to have surgery far away from home.
   
   When combined with the outsourcing of teleradiology, the implementation of pharmaceutical trials in foreign countries, the import of international medical graduates and nurses, the export of U.S. trained doctors, and the sharing of best practices across borders (Harvard, Cornell, Johns Hopkins, and Mayo are all involved overseas), medical tourism serves to illustrate the global convergence of medicine.
   
   A look at what is happening in the pharmaceuticals industry may be instructive for American physicians. Many Americans travel to Canada to purchase cheaper prescription drugs (sometimes as part of an AARP-organized bus trip) and are now allowed to bring back a 90 day supply without it being seizedContinuity of Care. Although there have long been policies to provide emergency medical care to those who travel, medicine needs to anticipate those that will travel solely for medical care, both domestically and internationally. There is concern over infectious disease migration, emergence, and control, as the patient may be exposed to bacteria and other microbes that they would not be accustomed to at home. In addition, different antibiotic resistance profiles exist internationally, meaning that a pathogen contracted overseas may need to be treated by some other antibiotic than what would be used in the U.S. for that same organism. The global emergence of infectious diseases like HIV and SARS have taught several valuable lessons with respect to the difficulties and costs of international efforts to manage disease migration after travelers contract novel agents abroad.
   
   On the level of an individual patient, some are also concerned about the fact that travel combined with surgery can increase the risk of blood clots. Insurance companies are not likely to cover complications from surgeries performed outside the U.S., meaning that American physicians and hospitals may be left to "pick up the pieces". AMA’s Council on Medical Service provided a report at the 2006 Interim Meeting, Postoperative Care of Surgical Patients, which explored the issues confronted by doctors providing follow-up care to patients cared for in other localities. This report detailed the proper use of CPT codes in OMSS Governing Council Report B – Page 9
   
   such cases, notably Modifier 55, which is defined as follows: "When one physician performed the postoperative management and another physician performed the surgical procedure, the postoperative component may be identified by adding modifier 55 to the usual procedure number". This modifier would be appropriate for use by physicians caring for patients treated in a foreign country, however, it is important to note that in order to bill Medicare using modifier 55, a written agreement between physicians must exist.
   
   Achieving Accountability in Global Health. ). Several other ethical issues have emerged in recent years:
   
   Women on Waves is a "floating" abortion clinic based on a ship registered in the Netherlands. "By sailing out to international waters before undertaking the procedure, the ship is acting under the legal jurisdiction of the country in which it is registered". The ship has met with mixed reaction in Ireland, Poland, and Portugal, where abortion is illegal. Plans for a floating euthanasia clinic registered in The Netherlands have yet to materialize.
   
   According to the CDC, ""Transplant Tourism" has been increasing as the number of available organs, especially kidneys, is decreasing relative to the increasing demand. A number of international transplantation rings have been discovered, in which people from developing countries are paid for donating organs. This practice is considered legal in only a few countries.
   
   Conclusions Medical Tourism as a Crisis Indicator
   
   The fact that Americans are venturing overseas for healthcare is indicative of a domestic health system in peril. "You can run, but you can’t hide from this mass of statistics that, taken as a whole, say we fall far short of having the best health care system," says James J. Mongan, MD, CEO of Boston’s Partners Health Care Systems, Inc. and Chair of the Commonwealth Fund’s Commission on a High Performance Health System, weigh down American employers, suppressing both wages and purchasing power. Health care is now 16% of the American economy.
   
   It is important to note that other western countries are also facing unsustainable healthcare costs. Waiting times and hospital infection rates make headlines in Europe on a regular basis, and like the U.S., Japan and Europe are fast aging; there is therefore much concern about the decreasing proportion of workers that will be paying into these countries’ healthcare systems OMSS Governing
   
   Council Report B – Page 10
   
   as utilization continues to climb. Combined with aggressive marketing tactics on the part of foreign countries, foreign hospitals, and U.S. based travel agencies, the stage is set for a significant new outsourcing stream.
   
   Will competition from abroad exert a downward pressure on US prices? It has often been said that arguing against globalization is like arguing against the law of gravity. The medical field may not have been the first to globalize, but it is unlikely to be completely immune to trends in the international health economy.
   
   Recommendations
   
   The Governing Council recommends that the following resolution be submitted to our AMA House of Delegates for consideration at its 2007 Annual Meeting:
   
   RESOLVED, That our American Medical Association (AMA) work with National Association of Insurance Commissioners and other interested parties to examine international medical liability issues (Directive to Take Action); and be it further
   
   RESOLVED, That our AMA work with The Joint Commission, The Physician Consortium for Performance Improvement, and the World Medical Association to develop policy in the area of international quality (Directive to Take Action); and be it further
   
   RESOLVED, That our AMA consider development of a separate CPT code for the post-operative care of surgical patients treated overseas (Directive to Take Action); and be it further
   
   RESOLVED, That our AMA develop model State legislation obliging companies that facilitate medical tourism to 1) require that the patient sign a form acknowledging that they have been informed of the differences in standards of care across countries, 2) provide for HIPAA-compliant transfer of the patient’s medical record, 3) arrange follow-up care prior to sending the patient to a foreign country, 4) ensure that seeing a physician in a foreign country is always voluntary, and 5) make facility outcomes data, physician licensing and outcomes data, and the patient’s rights to legal recourse, if any, transparent to the patient prior to care delivery (Directive to Take Action).
   
   The Governing Council recommends that this report be adopted in lieu of Resolution 6 (I-06)..AMA-OMSS JUNE 2007
   APPENDIX A
   
   

6. International Price Comparisons: Selected Surgeries$0$20,000$40,000$60,000$80,000$100,000$120,000$140,000$160,000$180,000Heart BypassHeart ValveReplacementAngioplastyHip ReplacementHysterectomyKnee ReplacementSpinal FusionUSIndiaThailandSingapore Procedure	US Cost	India	Thailand	Singapore
   Heart Bypass	$130,000	$10,000	$11,000	$18,500
   Heart Valve Replacement	$160,000	$9,000	$10,000	$12,500
   Angioplasty	$57,000	$11,000	$13,000	$13,000
   Hip Replacement	$43,000	$9,000	$12,000	$12,000
   Hysterectomy	$20,000	$3,000	$4,500	$6,000
   Knee Replacement	$40,000	$8,500	$10,000	$13,000
   Spinal Fusion	$62,000	$5,500	$7,000	$9,000

   Achieving Accountability in Global Health. ). Several other ethical issues have emerged in recent years:
   
   Women on Waves is a "floating" abortion clinic based on a ship registered in the Netherlands. "By sailing out to international waters before undertaking the procedure, the ship is acting under the legal jurisdiction of the country in which it is registered". The ship has met with mixed reaction in Ireland, Poland, and Portugal, where abortion is illegal. Plans for a floating euthanasia clinic registered in The Netherlands have yet to materialize.
   
   According to the CDC, ""Transplant Tourism" has been increasing as the number of available organs, especially kidneys, is decreasing relative to the increasing demand. A number of international transplantation rings have been discovered, in which people from developing countries are paid for donating organs. This practice is considered legal in only a few countries.
   
   Conclusions Medical Tourism as a Crisis Indicator
   
   The fact that Americans are venturing overseas for healthcare is indicative of a domestic health system in peril. "You can run, but you can’t hide from this mass of statistics that, taken as a whole, say we fall far short of having the best health care system," says James J. Mongan, MD, CEO of Boston’s Partners Health Care Systems, Inc. and Chair of the Commonwealth Fund’s Commission on a High Performance Health System, weigh down American employers, suppressing both wages and purchasing power. Health care is now 16% of the American economy.
   
   It is important to note that other western countries are also facing unsustainable healthcare costs. Waiting times and hospital infection rates make headlines in Europe on a regular basis, and like the U.S., Japan and Europe are fast aging; there is therefore much concern about the decreasing proportion of workers that will be paying into these countries’ healthcare systems OMSS Governing
   
   Council Report B – Page 10
   
   as utilization continues to climb. Combined with aggressive marketing tactics on the part of foreign countries, foreign hospitals, and U.S. based travel agencies, the stage is set for a significant new outsourcing stream.
   
   Will competition from abroad exert a downward pressure on US prices? It has often been said that arguing against globalization is like arguing against the law of gravity. The medical field may not have been the first to globalize, but it is unlikely to be completely immune to trends in the international health economy.
   
   Recommendations
   
   The Governing Council recommends that the following resolution be submitted to our AMA House of Delegates for consideration at its 2007 Annual Meeting:
   
   RESOLVED, That our American Medical Association (AMA) work with National Association of Insurance Commissioners and other interested parties to examine international medical liability issues (Directive to Take Action); and be it further
   
   RESOLVED, That our AMA work with The Joint Commission, The Physician Consortium for Performance Improvement, and the World Medical Association to develop policy in the area of international quality (Directive to Take Action); and be it further
   
   RESOLVED, That our AMA consider development of a separate CPT code for the post-operative care of surgical patients treated overseas (Directive to Take Action); and be it further
   
   RESOLVED, That our AMA develop model State legislation obliging companies that facilitate medical tourism to 1) require that the patient sign a form acknowledging that they have been informed of the differences in standards of care across countries, 2) provide for HIPAA-compliant transfer of the patient’s medical record, 3) arrange follow-up care prior to sending the patient to a foreign country, 4) ensure that seeing a physician in a foreign country is always voluntary, and 5) make facility outcomes data, physician licensing and outcomes data, and the patient’s rights to legal recourse, if any, transparent to the patient prior to care delivery (Directive to Take Action).
   
   The Governing Council recommends that this report be adopted in lieu of Resolution 6 (I-06)..AMA-OMSS JUNE 2007
   APPENDIX A