Alternate options for Caribbean medical evacuations
Is Miami the only option?
Traditionally, the Caribbean has not been well known for its ability to comprehensively treat certain patients, and those suffering from particular ailments are usually evacuated to Miami for treatment. However, Caribbean evacuation destinations are increasingly being considered thanks to their improved ability to treat cardiac and trauma patients, and their potentially cost-saving offerings. Here, we look at the reasons behind patient movements out of the Caribbean, assess recent healthcare developments in the region, and ask whether Miami will ever lose its allure as the preferred destination for regional patient evacuations.
Caribbean erosion
According to data from the Caribbean Tourism Organization (CTO), visitor numbers to the region are buoyant, with figures from the first six months of 2014 showing a 4.3-per-cent increase compared to the same period last year. The CTO estimates that, on average, there were some 77,000 visitor arrivals daily to the Caribbean – or 13.9 million visits – during the first six months of last year, approximately 600,000 more than a year ago. But these increasing tourist numbers have taken their toll.
As Sonia Valdez, marketing manager for Florida-based Jackson Health System’s International Program, told ITIJ: “Caribbean healthcare systems and infrastructures have not been able to keep up with the high demand for medical services.” The need to care for more patients is the result of a growing tourist market and an increasing population in the region, she explained. An additional financial burden on local hospitals and governments is created when, occasionally, tourists without (adequate) travel insurance ‘leave without paying for the treatment services received’, according to Carmen G. Mojica-Martinez, account executive for US-based international air ambulance provider REVA Inc.’s Caribbean operations, based in Puerto Rico.
What’s more, the geographic spread of the Caribbean islands doesn’t make for a cohesive healthcare system or easy access to nearby medical resources. Shai Gold, CEO of International-Triage Medical Networks and Assistance, said: “Most Caribbean island nations are small and have limited fiscal resources for investment in healthcare infrastructure. At the same time, the private sector is wary of making large investments in facilities due to limited case volume, the high cost of capital [resources] and patient preference for treatment in Miami.” This, in turn, has pushed high-calibre medical personnel to seek employment elsewhere, resulting in what Gold refers to as ‘a vicious cycle of perpetual erosion in human resource infrastructure’, adding that some of the premium cardiologists and other specialists in South Florida are from the Caribbean.
the geographic spread of the Caribbean islands doesn't make for a cohesive healthcare system
Although, in general, Gold says he has found the doctors working in the Caribbean to be resourceful and capable diagnosticians, he lists the issues affecting quality patient care in the region as: “Limited availability of specialists and sub-specialists, diagnostic capacity, front-line medications and uneven distribution of well-equipped facilities. A medical infrastructure requires an entire supporting team of nurses, para-professionals and technical service personnel, which is in limited supply throughout the Caribbean region.”
Dr Cai Glushak, international medical director and chief medical officer for AXA Assistance USA, agrees that there is a ‘pervasive’ inconsistency in the level of nursing care available locally, especially in intensive care settings, and told ITIJ that he has often found there to be a lack of highly skilled teamwork prevalent even in high-functioning Western hospitals in the Caribbean – something that is essential for a successful outcome when dealing with, for example, multi-organ dysfunction, septicemia and polytrauma cases.
In line with this reported lack of specialist care in the Caribbean, air ambulance companies such as REVA have witnessed patients being evacuated from some Caribbean hospitals not only with cardiac issues but also following cerebrovascular accidents and traumas. Neurosurgery, chronic illness, extreme premature care, cancer, and certain specialised surgeries are other areas where there are reported patient service deficiencies.
“Bacterial or viral internal medical infections, such as pneumonia and meningitis, are examples of manageable medical conditions that can become deadly in many Caribbean facilities,” said Gold, whose company offers a network of hospitals providing off-island care in countries including Panama and Costa Rica, adding: “While physician goodwill is in abundance, the vast majority of Caribbean healthcare facilities are unable to contend with severely ill or injured patients who require a state-of-the-art medical response. With few exceptions, air ambulance airlift is the most effective response to cardiac, stroke, trauma and neurologic emergencies.”
Miami has long been the go-to destination for these patients but, as we’ve seen, other destinations near to the Caribbean islands are becoming popular with assistance providers looking for an alternative. So, what has been the draw of Miami up to now?
Miami on sure footing
Miami’s close proximity to the Caribbean, its renowned reputation for high-quality medical care, and local hospitals’ ability to efficiently handle assistance cases is a winning combination. Some treatments in the Caribbean may be cheaper than in Miami, but with direct flights from many of the main Caribbean islands, and being within easy reach for aeromedical transports, Miami serves patients in need of specialist – and even non-specialist medical care – well.
Based on a strong foundation since the time when Jackson Memorial Hospital partnered with the University of Miami and its medical school in 1952, the city has always attracted renowned doctors and cutting-edge medicine: “Last year, the University of Miami received over US$330 million in grants towards research,” said Marco Flores, director of business development UHealth International (the University of Miami’s international patient department). Gold lists other key facilities in the Miami/Fort Lauderdale region as Broward General Hospital, Baptist Health System and Holy Cross Hospital. “The estimated value of exported medical services to the South Florida region is US$600 million per year,” he told ITIJ.
“For many years, Jackson Memorial Hospital and UHealth International have been the hub for Caribbean evacuations,” confirmed Sonia Valdez, who has witnessed this evacuation process for patients from the Caribbean, as well as from South and Central America, for the last four decades. And it’s the area’s reputation for such high-quality medical care that matters most.
“Hospitals and physicians in Miami have the standard of care required by the US government and regulatory bodies,” said Boris Garcia-Zakzuk, chief medical and underwriting officer at Florida-based Redbridge Insurance Company, adding: “And the technology available is top-notch.” In fact, today’s hospitals in Miami are said to be so optimally equipped, and able to offer a such a wide variety of specialist treatments, that insurance companies are known to choose Miami for it being the most fail-safe location. “European assistance companies, payers and patients face a constant challenge due to limited medical resources in the Caribbean region,” said Gold, “In this regard, triaging a case to a major hospital in Miami covers the legal, quality, risk, contractual and customer service bases for all stakeholders.”
In addition, hospitals in Miami have adapted to the needs of insurance companies, making the processing of patients from the Caribbean easier; something Dr Glushak of AXA Assistance has experienced: “A number of hospitals have clearly put a great deal of effort into ensuring their international departments make the acceptance process seamless, and other potential hospital destinations in the Caribbean are not quite as easy to navigate,” he said.
Plus, being able to offer a lower financial risk also supports cost containment, as Gold explained: “Latin American hospitals typically want an upfront deposit before admitting a patient. Given that 99 per cent of assistance companies are not risk-baring entities, they understandably favour the path of least financial commitment, which is [generally] only offered in the US.”
Caribbean advances
Significant advances in cardiac and other specialist hospital care on some of the Caribbean islands has been reported recently, and there is reason to believe that with continued development in regional medical infrastructure and treatment options, evacuations out of the Caribbean Basin might become less frequent than they have been in the past.
Although experts working in the region still report a wide variety in the standard of care available between the different islands, where generally the smaller, less populated islands lack the technology needed to reach a Western standard of care, ‘there are more points of light around the Caribbean than in the past’, said Dr Glushak.
Explaining that advances in both techniques and technology are being made, Flores of UHealth International said as an example: “The Caribbean community is now able to treat congestive heart failure patients with minimally invasive techniques.” Dr Garcia-Zakzuk of Redbridge has also witnessed improvements in invasive cardiac diagnostics and treatment in recent years, and told ITIJ: “Most Caribbean islands have primary care facilities; some also have secondary-care facilities; and few have tertiary-care facilities. Now, island hospitals have better radiation therapy equipment (too).”
the vast majority of Caribbean healthcare facilities are unable to contend with severely ill or injured patients
“While Caribbean hospitals are clearly not on the same professional tract as Miami hospitals, some encouraging signs of progress have been reported, and local islands of excellence are popping up on the radar screen of payers and assistance companies,” added Gold, who has found the current best cardiac provision and diagnostic, interventional and surgical capabilities within the Caribbean in Martinique (‘which is home to an impressive academic health system’), Trinidad, the Dominican Republic, Puerto Rico, and Panama City.
Dr Glushak, who has – over the last five to 10 years – also noticed an improvement in the level of acute intervention in locations such as Dominican Republic and Martinique, thinks these advances are feasible thanks to local economic developments. In fact, he has seen what he refers to as resultant ‘medical tourism’ to the region, whereby ‘a number of the medical facilities that have made considerable investment are actively seeking patients from abroad’.
Another observer of the significant medical advancements in Caribbean locations such as Costa Rica, Guadeloupe, Colombia and Cuba, Mojica-Martinez of REVA said there are now a variety of medical centres in Puerto Rico that can deal with transplants, cardiac, neonatal, cerebrovascular accidents and other conditions that need specialist care. “The local government [in Puerto Rico] has recently launched a medical tourism campaign to assist tourists with the appropriate referrals within the island because it is [substantially] equipped,” she stated. She added that patients from the US Virgin Islands, as well those from the British Virgin Islands, Antigua, Anguilla, Nevis, St Kitts, and St Maarten are now increasingly being transferred to hospitals in Puerto Rico.
There are other islands in the Caribbean that are quelling the outflow of patients to Miami too. Reminding us that it was only a decade ago when the most critical patients were evacuated from the Dominican Republic, Dr Glushak said: “Now, most can be handled at a major medical centre in that country (the Dominican Republic) and this location has become a destination for evacuations,” adding: “At least there are now other options besides Florida for many conditions.”
patients are also reportedly being evacuated out of the Caribbean to avoid potential overcharging
Gold, meanwhile, whose own International-Triage Medical Networks and Assistance makes use of several key providers in Panama City where, as he told ITIJ, cardiac, stroke, trauma and neurosurgery patients are being catered for to US-standard diagnostics, has noticed more recent transfers to Panama from the Caribbean coast of Central America and some from the Southern Antilles. He also confirmed that Martinique has become the preferred medical hub for European Union patients from the Central and Southern Caribbean: “Once they set foot on the island, the cost of their care is directly billed to their government’s ministry of health; this is a high incentive for shifting cases [away} from Miami.”
Looking to the future
Despite medical advancements in the Caribbean, especially with regards to the treatment of cardiac cases in some areas, patients will still be sent to Miami, particularly for the most serious, complex or specialist treatments, say some experts. Flores of UHealth International, for example, confirms: “Still, the more acute or critical patients have continued to seek treatment or intervention in the United States.”
There are other reasons for evacuation to Miami, though. For example, a Caribbean hospital may be able to meet a patient’s needs, but there may be no available beds; while several insurance companies have contractual agreements with Miami. Some patients are also reportedly being evacuated out of the Caribbean to avoid potential overcharging in local hospitals. There may also be a preference – or financial need – for a patient to be treated nearer to home (i.e. in the US, for US insureds), especially in cases where a prolonged recovery is necessary, explained Mojica-Martinez.
Caribbean hospitals are offering an attractive incentive in some cases, however. “Panama and Colombia are on the rise for having excellent quality of medicine at a much lower cost, and while many patients from the Caribbean still come to Miami, [there is a growing tendency] to steer them to Panama, Puerto Rico, the Dominican Republic or Colombia,” said Dr Garcia-Zakzuk. REVA can also see a future for medical evacuation destinations such as Martinique and Guadeloupe. Gold encourages this new trend because some Caribbean hospitals are now able to ‘offer quality care on par with Miami at a markedly lower cost’.
But, evacuations from the Caribbean to Miami will never stop entirely. “They are a fact of life,” said Gold, who added: “While [alternative] options have emerged, factors such as risk management, family pressure and simplicity in access and reimbursement are likely to remain important factors in the decision-making process of payers and assistance companies.”
It all comes down to offering that winning formula. Dr Glushak, who has seen several new Caribbean hospitals being built in key locations such as the Jamaica islands and Grand Cayman, told ITIJ: “We have also heard that some companies have (also) evacuated to Cancun, but it remains to be seen if [locations other than in Miami] will offer a quality and cost advantage. They will need to offer both technical capability and medical expertise at reasonable cost. If any of these three factors is missing, there will be no reason to choose them as a destination.”