Agent Issues Medical travel can be lucrative, but fraught with complexity Part 2 of Travel Weekly's Focus on Medical Tourism By Nadine Godwin / August 22, 2012 Share 1 -- The package for a client traveling overseas for medical purposes could include meet-and-greet services on the jetway, a hospital staff that handles the baggage, even massages in a hospital room large enough to accommodate sleepover relatives. These are just examples of what might be offered by a hospital, not a travel company. In addition, the hospital staff-to-patient ratio can be double that found in the U.S., according to David Boucher, president of Companion Global Healthcare, a medical travel facilitator. Yet with all this pampering, he said, the cost savings to Americans for major procedures can be as much as 75% to 90%. For dental work, the savings can range from 50% to 75% Just the same, medical travel can be nerve-wracking for the patient. For American medical travelers, typically ages 50 to 65, the trip generally requires 10 to 20 days away from home, and it can involve "in-country support with companions," Josef Woodman told delegates to the Well-Being and Medical Travel Conference 2012, held this June in Scottsdale, Ariz. The patient needs "trusted support for the logistics," said Woodman, who is CEO of Patients Beyond Borders, consultants and publishers of reference materials for medical travelers. "This is more complex than just booking air on Travelocity." Further, although many patients have traveled internationally before seeking treatment, about a third have never owned a passport. Mixing a lot of truth with a touch of hyperbole, the printed program at the Scottsdale conference stated that these neophytes "are traveling to a country they don't know much about for surgery by a surgeon they have never met coordinated by a company they never heard of and conducted in a language they don't speak." Enter the travel agent. Intentionally or otherwise, most agents have bypassed that stage cue. The situation is changing, though, as indicated by the Scottsdale conference, which was sponsored by Well-Being Travel, a unit of the American Marketing Group (AMG), parent of Travelsavers. For its affiliated agencies, Well-Being Travel selected a preferred medical travel facilitator and a preferred complications insurance provider. Almost simultaneously this summer, the Medical Tourism Association launched a program to train agents as specialists in the field of planning medical travel. That's not a coincidence. Looking ahead a few years, Ted Cromwell, a former travel agent and Hickory executive, is betting that agencies of all sizes will expand their role to become medical travel facilitators. He plans to launch a business by Jan. 1, if not earlier, to provide insurance and training support for that evolution. In addition, although they aren't ready to announce it publicly, a few corporate agencies already are considering becoming medical travel facilitators, professionals trained to offer patients a selection of appropriate care providers, transfer medical records and make the appointments. Ideally, they are working with a network of providers that they or their partners have vetted for quality. For now, however, most travel agents are not prepared or inclined to take on the liabilities that being a facilitator implies. They might refer clients to or receive referrals from facilitators, with a view to booking the actual travel. A few agents have tested these waters. It was a natural for Kathy Kocharhook, who is both owner of Sail-n-Travel in Cupertino, Calif., and a registered nurse. She participated in a medical tourism fam to Thailand in 2011 because "I wanted as much experience as possible and wanted to experience some services." She arranged for preventive care in Thailand. In Costa Rica this summer, she arranged for on-site dental services. She will attend the Mexico Travel Health Forum in Puerto Vallarta this month, as well. Kocharhook accompanied her first (and so far, only) medical-travel client to Thailand. "It was a business experience and investment," she said. The experience taught her that medical travelers have more needs than most other clients, and for that reason their trust is "more important than ever." The agent must not recommend the medical care, she said -- that is the role of the facilitator -- "but the agent still needs to understand what the client's needs are" in order to get the right services to complement whatever the hospital might offer. For that reason, Kocharhook said, "the client divulges more personal health information than usual. It's a different arena for trust." In addition, she said it's important to anticipate issues: for example, urging the client to book for a longer trip than the doctors recommend. Moreover, she said that no matter how gracious the hosts at the destination, the experience can be intimidating. For that reason, the agent should be ready to explain what will happen at the destination. It is important for the client to be accompanied and "handheld as much as possible." Kocharhook's preferred facilitator is Thailand Medical Travel & Tourism in San Diego, where Kiana Bright is vice president. Bright, a speaker at the Scottsdale conference, said special needs also might include early hotel check-in, an in-country personal assistant and sightseeing options with a lot of flexibility in the event the patient does not feel up to touristic activities. Kocharhook said she is a "big believer" in insurance but had not even known complications insurance was available when she booked her first client. Staci Blunt, owner of Vacation Visions in Chandler, Ariz., said she offered travel insurance to the 30 or so medical travelers she has served, but since most are self-payers, she said, "they usually don't take it; they are so eager to save money." Speakers at the Scottsdale event recommended booking medical travelers in business class or other premium service, partly for flexibility to reschedule if necessary. But Blunt said that for her cost-conscious clientele, it was "still cheaper with a nonrefundable ticket even if you have to make changes. The client just pays for the changes." She said her customers, who traveled to either Costa Rica or Mexico, used "regular hotels, not resorts, usually [European plans]. Some wanted nice, familiar hotel brands." The hospital packages could include some or all transfers and a bed for companions staying in the hospital room. Blunt said she filled in whatever the hospital package did not include. Her business came in the form of referrals from a facilitator, MedToGo, in Tempe, Ariz. Although she did not help choose health providers and does not speak Spanish, she had dealings with the hospitals. Now, she said, she is handing off the referrals to an agency with Spanish-speaking staff; she will be the backup. Some overseas hospitals provide all-in quotes for medical care plus transfers or other services. Woodman told his Scottsdale audience there is the opportunity for travel companies to organize co-branded packages. When Well-Being Travel was created in 2010, it announced it would create medical travel packages that include air and hotel. A spokeswoman said there should be "more news on that" later this year. Shark repellentsA key reason travel agents are not often seen in the medical tourism arena is fear of liability should something go awry during a client's out-of-town medical procedure. That risk is real, said Mark Pestronk, travel attorney and Travel Weekly columnist. Still, he added: "This is a good area. It is growing, lucrative and, for the agent, a chance to do good for clients." Pestronk told delegates to the Scottsdale conference that U.S. courts rarely hold agents liable for the failures of suppliers or for "acts of God." However, he said there has never been a case where an agent was sued after something went wrong on a client's medical trip, so there is no reassurance to be taken from court precedents. Besides, international medical trips produce their own "huge legal problem," Pestronk said. It's not about whether the agency can be held liable for someone else's failure. It's about finding someone to sue. He called it the "shark's dilemma," the shark being the plaintiff's attorney, who can't sue foreign doctors and foreign hospitals in the U.S. because the courts, with a few exceptions, don't have jurisdiction. The U.S. Supreme Court has ruled one cannot sue anyone in the U.S. unless that defendant has minimal contacts here, such as working, entering contracts or advertising here. Pestronk said the plaintiff's lawyer could associate with an overseas lawyer and sue overseas, but the legal systems in almost all medical tourism destinations "don't provide meaningful compensation in malpractice cases. Israel is the exception. In other countries, there is no such thing as a contingency fee, and damages are small. If you pay Third World prices, you get Third World damages." In addition, in some countries, there is little malpractice law, or litigation takes longer than in the U.S., and the plaintiff may have to appear in court. Pestronk made his point with eye-opening examples. In India, he said, malpractice awards are "in the low thousands [of dollars]. There is nothing for loss of earnings, nothing for pain and suffering, no plaintiff's experts, and cases can take 15 to 20 years. The parties dispose of records when a problem arises, and courts can't enforce a judgment." In Mexico, he said, the estate of a dead plaintiff can collect only $17,800 maximum, and an injury award would be four times the minimum wage in that country, which is $4 a day. As a result, he said, there are more malpractice cases in the U.S. brought by Mexicans and Americans against Mexican health care providers than there are in Mexico. Given those realities, Pestronk said, "the shark goes after the little fish, the travel agent." In addition, given that the case is about major medical complications, the shark will be someone "used to multi-tens of thousands of dollars in settlements." Pestronk offered delegates the "Pestronk shark repellent kit": • Get a signed disclaimer and release, in which the client releases the agency from all claims of negligence. In most states, this is effective, he said, provided the concepts are clear and brought to the clients' attention. Travel companions as well as the patient must sign, he said, "no doubt about it." He offered a copy of his model disclaimer at www.pestronk.com/free.html but urged delegates to discuss it with their own attorneys. • Always use a medical travel facilitator. American agents should use a U.S.-based facilitator, he added. Don't recommend any health care provider or even a destination for treatment, he urged, so the liability shifts entirely to the facilitator. Besides, he said, if there is a contract between the U.S.-based facilitator and the foreign hospital, the shark could sue both in the U.S., "and the judge would be very reluctant to dismiss the hospital from the case." That's not to say there is a guarantee that such contracts will establish U.S. jurisdiction over the foreign facility. For that reason, he said, when considering a facilitator with which to partner, it's a good idea to ask if it has contracts with the facilities it uses, which would improve a plaintiff's odds of getting U.S. jurisdiction. • In the agency contract with the facilitator, he said, "make sure the facilitator indemnifies you and pays your legal fees" in the event of a post-trip malpractice suit. (For agencies affiliated with Travelsavers or the Network of Entrepreneurs Selling Travel [NEST], Well-Being Travel has tapped Companion Global Services of Columbia, S.C., as its preferred facilitator. This deal does not provide blanket indemnification for all Travelsavers and NEST agencies that refer clients to the facilitator.) • Offer a medical travel insurance policy. "Making the offer is the most important thing, regardless of what the client does," Pestronk said. He urged agents to not attempt to interpret the insurance policy, instead referring clients to the insurance company. Finally, he recommended that agents study their errors-and-omissions policies to determine if they cover medical travelers. Separately, Greg Takehara, senior vice president at Berkely Travel, provider of most agency E&O policies, told Travel Weekly that Berkely's policies have "no specific exclusion governing medical trips, but ... an allegation against an agent for negligently selecting a medical facilitator, that would not be covered. If there were a nonmedical accusation against an agent [regarding] a medical trip -- i.e., a visa issue, wrong date, hotel problem -- there very well could be coverage." When asked about booking travel for inbound patients, Pestronk said his disclaimer would not protect agents against charges of negligence in the E.U. and other countries. "Consult a lawyer in the country the patient is coming from," he advised. Speakers at the Scottsdale conference urged agents to promote their services to all clients, including corporations. But Pestronk warned that those who hold themselves out as specialists to businesses will be held to a higher standard of care if they are sued. The disclaimer is the "first line of defense," he said, along with the other components of his "shark repellent kit." Complications insuranceAt least two insurance companies offer coverage tailored for medical travelers who are treated outside the U.S. Both products were introduced in the last three years, and both companies sell through agents. Because the policies, often termed "complications insurance," are for a range of procedures with different price tags, the premiums vary widely. They could range up to several thousand dollars if the procedure is major, such as heart surgery. The insurance companies are Custom Assurance Placements of Columbia, S.C., and Seven Corners of Carmel, Ind. Almost all standard travel health insurance policies will not cover a traveler for any incidents occurring during a trip whose purpose is medical treatment. MH Ross Travel Insurance Services is an exception. According to Paul Salamone, vice president of sales and marketing, MH Ross will sell its standard policies to medical travelers "but cancellation must be for anything other than the medical procedure. [Clients] could get hit by a bus." Custom Assurance's Global Protective Solutions is the preferred supplier for AMG's agency groups, Travelsavers and NEST. Global Protective Solutions covers expenses triggered by complications that occur during the first six months after the medical procedure, and, like standard policies, it covers for travel-related accidents. The policy will be amended to cover for unrelated illness, as well, said Tracy Simons, president of Custom Assurance. Benefits include an emergency assistance service, available 24/7. Simons said patients must use an approved overseas facility that is accredited by the U.S. accrediting organization known as Joint Commission International (JCI) or an equivalent accrediting organization. The policy does not cover baggage, nor does it cover trip cancellation or interruption. Except by special exception, it is not available for travelers under 18 or over 70, and it does not cover pre-existing medical conditions that are unrelated to the reason for the medical travel. It will be sold exclusively through Travelsavers and NEST agencies, plus any U.S. and Canadian agencies that register with AMG's Well-Being Travel. Agencies that have previously sold the product are already effectively registered. The Seven Corners product, Bordercross Worldwide Medical Procedure Insurance, covers for complications that occur within 60 days of the medical procedure, but patients must choose one of the world's 350 JCI-accredited facilities if they require inpatient care. This policy also excludes pre-existing conditions, but it covers more events that are included in standard insurance policies. According to Valerie Baker, customer service representative, Bordercross covers for illness or accidents unrelated to the medical procedure, trip cancellation and interruption for reasons related or unrelated to the medical procedure and medical evacuation. It also covers for lost or damaged baggage. If the patient has a traveling companion, he or she must also be insured. Bordercross marketing director Suzanne Munson said some hospitals are embedding this insurance into the pricing of their treatment packages. The learning curveLast month, the Medical Tourism Association (MTA), an international organization of health care providers and buyers, launched a program to certify agents as medical travel specialists. Jonathan Edelheit, the association's CEO, said, "We will educate agents about the roles of others [in the field], what to expect from the medical travel facilitators and how to protect themselves from liability." To be certified by MTA, agents must attend, in person or via the Web, an MTA-created, eight-hour training program and pass an exam. The cost of the training, exam and certification for two years is $1,500. Renewals, good for three years, are $500. There will be ongoing education requirements. The first course will be offered Oct. 27 after the MTA's annual conference in Fort Lauderdale. The online version will be available by Dec. 1, the MTA said. Edelheit said 100 to 200 agents usually attend the MTA's annual conferences, but that number will probably be higher this year because of the certification program and because the MTA has been "in discussions with several travel [entities] on creating a joint project to educate their agents." He said he was not free to name any prospective partners at this time. Edelheit said the MTA will have a search function at its website so medical travelers can find MTA-certified agents or validate that an agent is certified. The association, he said, launched a certification offering for medical travel facilitators two to three years ago. The same committees, with input from two travel agents, modified the facilitator program for the trade. "We wanted to know how agents think and what role they were interested in having," he said. "They will be handling the travel, not the medical records." For the agent, he said, "the key is to get the waiver [disclaimer and release described by Pestronk] from patients and to choose the right facilitator. We will show agents how to pick facilitators. ... The facilitator is the potential source of liability" if the agent makes a poor choice. "Some facilitators have been found guilty of criminal activity that is shocking," Edelheit said, including "swindling doctors, and one is under investigation by the FBI." The Hartford Courant reported the city of Hartford, Conn., last fall canceled its contract with a facilitator after learning the firm's founder had been convicted of wire and mail fraud, sentenced to 51 months in prison in 2004 and ordered to pay $36.4 million in restitution. The city, facing big health care costs, has not given up on medical tourism, however. Edelheit said, "We would suggest one of our MTA-certified facilitators or that agents pick up the phone and check references. Too often people don't do that." Anne Marie Moebes, executive vice president of Well-Being Travel, also suggested that agents ask if their prospective facilitator is paid by medical facilities for delivering customers, the presumption being that if the facilitator is paid in that way, the facilitator's advice may be biased. Well-Being Travel vetted and selected Companion Global Services as its preferred facilitator. Patients or their employers pay Companion Global for services. Any agency could piggyback on the vetting undertaken by Well-Being Travel or, in the future, other trade groups. At the Scottsdale conference, Moebes said her organization hoped to provide another training option through the Travel Institute. Patty Noonan, director of sales for the Travel Institute, confirmed there had been discussions regarding a medical tourism module, but the challenge is to find someone to underwrite the project, she said. Fam trips are another learning alternative. The Tourism Authority of Thailand (TAT) operated fams to Thai hospitals in each of the last two years, most recently in June, for a total of about 25 participants, said Peggy Peterka, TAT marketing manager in Los Angeles. As these fams become more popular, she said she expected TAT to "extend our reach ... in invited guests." Piyalak Intognkum, a marketing officer at TAT in Los Angeles, added that this year's itinerary included sightseeing and up to two visits to medical facilities per day. It also provided a personal experience with services, a half-day general checkup. She said participants were representing self-insuring corporations as well as travel agencies. Agents as facilitatorsCromwell said he plans to create a business that makes it realistic for agencies of all sizes to be medical travel facilitators, because he believes the addition of facilitator services is "a natural" for the growth of the agency business. It makes sense, he said, that patients would want to deal with one source for travel and medical arrangements. Besides, he said, travel agents, with their customer-service experience at the personal level, are natural candidates to provide a one-stop service that includes the medical planning. However, if liability is a worry for those selling medical travel, it is much greater for agents who would be facilitators. Cromwell said his new firm, as yet unnamed, will combine the training designed to give agents more confidence in their own abilities with insurance to cushion against liability. There is insurance for facilitators today, he said, but his plan would require agents to be certified as facilitators to qualify for his insurance. The facilitator certification program will be aimed only at travel agents, and for now, only those at ARC-affiliated agencies. Cromwell said he is not sure how he will deal with independent contractors. The certification, a proof of expertise, would help control the cost of premiums, he said. Also, premiums would be priced based on the number of people who are certified at a given agency, which is why Cromwell said he believes that small or midsize agencies, as well as the megas, could be facilitators. The new firm also will offer certification for agents wishing to sell medical travel without being facilitators, he added. Since the MTA already offers these certification programs, Cromwell said he is discussing with the MTA the possibility of implementing some part of his program through the association. Cromwell was, until this summer, an executive vice president at the Hickory corporate agency trade organization. Previously, he was a senior vice president of BCD Travel. Gay Nagle Myers contributed to this report.