First published in ITIJ 92, September 2008
The Caribbean Basin boasts many seemingly idyllic resorts with sun-kissed beaches and crystal clear seas, but when things go wrong, local healthcare facilities can be less attractive. In the first of our features to bridge the gap between ITIJ and PHN, Petra Kendall-Raynor has the details
The Caribbean Basin region can be defined as a large area from the coast of Florida in the United States stretching to the northern coast of South America and taking in Mexico, Central America and the West Indies along the way. The area is home to around 37.5 million people and, according to the Caribbean Tourism Performance scale, in 2005, 22.5 million people visited the region, which is host to stunning scenery. As a consequence, the Caribbean Basin has become a giant playground for millions of tourists who return year on year to take time out of the rat race, soak up the sun and indulge in the activities on offer.
A decade ago the Caribbean Tourism, Health, Safety and Resource Project cited the area as the most tourist dependent region in the world. Tourism was expected to generate $32 billion of economic activity in 1998 and contribute to a quarter of the GDP. Total economic activity by the tourism industry should reach $40.3 billion, predicted to growing to $81.9 billion over the next decade.
Illness and injury
But the dream of an idyllic getaway can inevitably turn into a nightmare when illness or accident strikes. Last year, British tourists were struck down with a stomach bug outbreak in the Dominican Republic and were so ill with vomiting and diarrhoea they had to be treated at a local hospital.
One guest told a national newspaper: “It’s been hell on earth. Every day we see a child run to the toilet to be sick – often not making it. Hotel bosses seem unwilling to co-operate and won’t answer questions.”
Lawyers at award-winning travel law specialists Irwin Mitchell have dealt with dozens of cases of cruise ship passengers who have contracted various illnesses including E-coli and the Norovirus. Robert Ladle, a 60-year-old from Leeds, suffered severe poisoning in January 2007 while on a Caribbean cruise. The holiday was a 60th birthday celebration for him and his wife. His lawyer, Jenny Brooks from Irwin Mitchell, said: “This outbreak of dysentery, which ruined what should have been a special holiday for Mr Ladle, could easily have been avoided if stricter hygiene and sanitation measures had been put in place. We have repeatedly called for more to be done to improve safety standards on cruise ships. Tighter regulation and independent inspection of cruise liners is needed to avoid further illness outbreaks, which cause significant suffering to passengers.”
In 2006, a 14-year-old American teenager was killed in a jet ski collision in the Bahamas. He was visiting from New Jersey and collided with a boat. In 2002, the two-year-old son of a British couple died in hospital after being hit by a speedboat.
Bupa has invested millions in the Latin American and Caribbean market
On top of unexpected illness and accidents, tourists may also be the victims of natural disasters. In 2007 hurricane Dean struck through the Caribbean sea, causing millions of pounds worth of damage and claiming 42 lives. The eastern region of the Caribbean is prone to hurricanes from June to November. In 2004, Grenada was severely damaged after Hurricane Ivan swept through the island, resulting in a total breakdown of transportation and communication. In November last year, an earthquake measuring 7.3 on the Richter scale hit Martinique and St Lucia, with both tourists and residents experiencing injuries following structural damage to buildings.
If a holiday does not go according to plan and a medical emergency occurs, it could cost thousands of pounds for tourists to be returned to their country of origin. The UK Foreign Office website warns that if a tourist needs to be returned to the UK it could cost £30-35,000 for an air ambulance from the east coast of the USA. It is careful to caution that the British Embassy or High Commission will not pay for this and tourists should have adequate travel insurance, with medical or health cover for an injury or sudden illness abroad. Users of the website are told that cheaper policies will usually have less cover and they should shop around to find the right product rather than travel with no cover at all.
Bupa has invested millions in the Latin American and Caribbean market and works with local insurance companies in Mexico, Ecuador, Dominican Republic and in South America. But it is not just tourist coverage, there is a huge expatriate market seeking adequate healthcare. The company bought two health companies, Amedex and IHI Denmark in 2005, increasing their access to the expatriate market. Earlier this year, Bupa International launched five health insurance plans to meet the healthcare needs of people living in the region who want treatment at home or overseas.
Following the launch of the health cover, David Maltby, managing director of Bupa Latin America said: “Many Latin Americans often travel overseas for medical treatment which is why we have designed our new products to fit with peoples’ different lifestyles and health requirements. It also makes things simpler for customers. So whether you are looking for cover for diagnosis and everyday treatment or a fully comprehensive plan with no monetary limits, there is a policy to meet your needs and those of your family.” The Bupa Essential Care Hospital Network offers members access to 50 hospitals and clinics in the US, as well as a wide range of hospitals in the Caribbean basin region. Other insurers in the region include the Government of Bermuda, Caribbean Insurers (Health) Limited, BF&M and The Argus Group.
The perceived and actual lack of high quality medical services in the area has led to several Caribbean-based insurers offering health insurance products for residents and ex-pats. Ray Parry of Strategic Claims Network (SCN) said that on cases that his company has been involved with, all policies provide for treatment in North America. For these there seem to be two main areas of choice, The North Eastern US (centred around Boston) and Southern Florida (centred around Miami). In his experience, insureds have been able to choose the facility that they want to be treated at with little or no interference from the insurer. This is probably because premiums are very high and insurers tend towards keeping the client happy no matter what. He added: “Although on relatively rare occasions the policy will be approaching its lifetime limit and insureds are forced to pay for treatment themselves. In these cases we can usually get the facility to lower their treatment costs.”
in the Cayman Islands there is still not much of a medical infrastructure
The result, continued Ray, is that choices are often made on the recommendation of family and friends or perhaps a local medical professional. Inevitably, this leads to a reduction in the levels of discount that could be obtained had the insurer directed the client. Recently, SCN’s sister company Assured Medical Associates has seen insureds seeking treatment in Canada, particularly for diagnostics such as colonoscopies and some neo-natal treatments. (this is a juxtaposition as AMA is also seeing an increasing number of Canadians who want treatment in the United States).
David Angelone, chief executive of cross border solutions, United Health International said that in many areas of the Caribbean, primary care is quite good, but complex cases often need to be transferred to the US for treatment: “South Florida offers some of the most advanced treatments and facilities in the world,” said David, “And with our proximity to the Caribbean, it is easy to transport patients here when required.” UnitedHealth has a network of over 200 hospitals and 25,000 physicians in Florida alone, handling the medical needs of 2.5 million people. In addition to the advantages of geographic proximity and unit cost discounts, David also believes that the sophistication of United’s care management processes help ensure that patients are receiving the most effective care in the most effective setting. “Our patients are tracked from admission to discharge in the case of hospital care, our providers follow evidence-based best practice guidelines, and our post-discharge follow-up procedures provide patients with the assurance that they are receiving top-notch care. We do not see the US system supplanting the Caribbean systems so much as supplementing them,” he added.
Baptist Health South Florida’s hospitals, including Baptist Hospital of Miami and South Miami Hospital, have a long history of treating expatriate employees stationed in Latin America and the Caribbean. “We have had the pleasure of working with many countries, governments and other official agencies, in treating their expatriate employees stationed in the region. Our bilingual staff of over 50 representatives is trained to cater to the special and urgent needs of international patients and their family members. In addition to coordinating all their medical and local lodging needs, they also deliver unbeatable personalized care”, said Allen J. Brenteson, Corporate Vice President of Baptist Health International Center of Miami.
Tourists who do encounter difficulties finding the right care in the Caribbean may be flown to the US for essential treatment and Jackson Memorial Hospital, along with Baptist Hospital and South Miami Hospital in Miami, Florida act as nerve centres for tourists coming from the Caribbean. Shai Gold, former vice-president of international medical services at Jackson Memorial, says the staff at the hospital have expertise in handling tourists who suffer from complex and acute cases.
The Florida Hospital Gamma Knife Center is also a key referral centre for physicians and patients from the Caribbean, Latin America, and South America. The hospital is an acute care health system and specialises in surgery where they use finely focused beams of gamma radiation with minimal effect on surrounding normal tissue and without the usual risks of surgery or an incision.
The Miami Medical Alliance, meanwhile, is made up of several hospitals including, Aventura Hospital and Medical Center, Baptist Hospital, Cedars Medical Center, Mercy Hospital, Miami Children’s Hospital, Miami Heart Institute and Medical Center, Mount Sinai Medical Center, South Miami Hospital, and Jackson Memorial. They all treat patients in their international departments and the indgenous population of the Caribbean and Latin America can sometimes even be referred for treatment by a doctor in their home country to take advantage of the advanced medical treatment. Other popular choices on the Eastern Seaboard are Mass General, Lahey Clinic, Johns Hopkins and Dana Farber Cancer Center. All of these facilities derive millions of dollars annually from Caribbean insurers. While the situation in Canada can be difficult, Parry says SCN is seeing an increase in the number of Caribbean insureds going there.
some hospitals will try to take advantage of tourist patients if they know they will only be there for a one-off visit
In terms of tourism, Mr Gold explains: “There are millions of tourists on vacation in the Caribbean and quite a few of them engage in sporting activities.” He says that the range of seemingly harmless pastimes can often end up with tourists suffering serious injuries: “I know people who have been driving a golf cart while intoxicated and it has overturned, riding a jet ski where people are swimming, and not obeying warning signs when scuba diving. Even looking at a girl in a bar the wrong way could lead to problems, with tourists being attacked. If you go to a destination which is an exotic island, you can contract an exotic bug.” He says that anyone coming into the hospital would be screened and financial clearing would be pre-requested. Mr Gold reveals that British tourists usually have wall-to-wall coverage, whereas other European tourists may not.
Some islands do not have specialist medics like cardiologists as they are often difficult to recruit because they would lose their skills if they were covering a very small community. But, admits Gold, Panama and Colombia offer excellent healthcare and there is a brand new hospital in Antigua. He adds that Guadalupe and Trinidad also have more than adequate medical facilities, but Barbados and Cayman Islands vary in the level of complex cases they can treat: “It is fair to say that elsewhere in the region there are hardworking health professionals who do their very best for patients – but the best doctors and nurses in the world cannot work without the correct infrastructure.”
Tourists coming into Jackson Memorial may require an even smoother entrance than other patients because they are coming back to reality with a health crisis during a fantasy holiday, says Gold. A medical concierge will meet the tourists at upon their arrival at the hospital and provide ‘lifestyle support’ similar to a hotel or cruise ship. Mr Gold says the concierge acts as a bridge between the lifestyle and medical needs of the patient and will pay attention to little details such as a bathrobe and slippers and may even act as an advocate on behalf of the patient as an ‘extension of the family.’
In terms of insurance, he says that some tourists will have insurance that does not recommend certain hospitals: “The insurer then becomes the villain in the eyes of the patient.”
His hospital, however, offers a Direct Access membership service where customers receive a gold card and are pre-registered on the hospital database. It will also act on the patient’s behalf and hire a licensed air ambulance company to transport them to the hospital as quickly as possible. However, members must sign an agreement form authorising the hospital to use their credit card information to pay the air ambulance company for air and ground service as needed.
Air ambulance costs range from $6,500-$25,000 from the Caribbean islands, £18,000-$25,000 from Central America and over $30,000 from South America. Mr Gold estimates that a simple case of someone with broken bones would cost around $2,500, but a more complex case of someone involved in a car accident with multiple fractures and lung problems could stay in the hospital for three to four weeks at a cost of $500,000-$700,000: “We work with insurance companies to ensure we decrease the cost of stay by trying to get a discharge plan as soon as possible. I can’t emphasise enough how important it is for people to buy insurance.”
Some air ambulance companies offer competitive deals and low-cost membership in a bid to ‘protect’ tourists from costly air evacuations. If you are a member of MedjetAssist, for example, and in a hospital more than 150 miles away from home, the company will send a medically equipped and staffed aircraft to pick you up and fly you to the hospital of your choice at no additional charge. Regular membership ranges from $225 a year for an individual up to $1,450 for a five-year family membership.
Air ambulance company AirMed medical department manager and chief flight nurse Michael Key has been on more than 550 medical missions to over 70 countries and regularly travels onboard flights from the Caribbean. He admits that sometimes there is a lot of red tape surrounding the evacuation of tourists: “By the time we get the call, we need to know that the person will be able to pay upfront or have coverage. These are $8 to $9-million dollar airplanes and it is a business.”
Key says that he has seen some people without coverage pay for the bill on five or six credit cards, but admits it can be ‘heartbreaking’ when they can’t help someone despite having the facilities. He says over 10 years, he has transported around 650 patients with various problems: “We deal with a lot of trauma; it sometimes can be as simple as someone looking the wrong way crossing the road and getting hit by a vehicle. We also deal with a lot of high-risk obstetric cases.”
For those who cannot be initially transported out of the country, some healthcare facilities in the region can present a range of problems for assistance companies. Medex Assist offers international travel, medical, security evacuation and assistance services to around 13 million people per year. They also offer pre-trip medical and security intelligence. Pascaline Wolferman, director of the emergency response centre and resource development at the company, says a lot of tourists from Canada and the US travel to the Caribbean basin from November to April. She says the main destinations are Mexico and the Dominican Republic: “When people travel they always think of exotic illnesses, but in reality a lot of the main issues we have are traumas and cardiac conditions.”
Wolferman says the company tries to reach the travellers before they go abroad, offering them information about the area and online support. She reveals that some hospitals will try to take advantage of tourist patients if they know they will only be there for a one-off visit: “In Mexico we’ve had cases where someone from the ER will drive the patient to a cash machine before seeing them in a treatment room.”
There are some local assistance companies who pretend to be able to negotiate excessive bills
Some hospitals might even be in collusion with private air ambulance companies and tell a patient they need to be evacuated by air immediately at a cost of $4,000, when in fact it is unnecessary. “If that is the way they function, they have some very serious ethical issues and are trying to live from the tourist population,” Ms Wolferman adds. However, she says, Medex Assist has local providers they trust: “If a hospital does not perform as it should, we are not going to refer anyone to their facility. In areas where there has been trouble, we will visit them and have to deal with it.”
The International Center’s Patient Services Offices, which are located at South Miami Hospital and Baptist Hospital, are routinely called upon to co-ordinate air ambulance transfers from leading cruiselines such as Royal Caribbean and Carnival Cruiselines navigating in the Caribbean, as well as other island destinations, including the Yucatan.
Some hotels can also be unscrupulous with their all-inclusive packages, including medical care on-site. In certain situations, Ms Wolferman says she would advise tourists to get a taxi, get out out of the hotel, and the company will tell them where to go: “These are very big issues for us.” She says in the Dominican Republic there are not many options in terms of local hospitals and clinics for the company to work with: “For a minor injury you may still have to put up with their charges, but it is still in the patient’s best interests to be there. We would review cases and bills because that way we can look at over charging. There are definitely some areas of the Caribbean where overcharging tourists is a big problem.” Wolferman reveals two examples are the Dominican Republic and the Riviera Maya in Mexico and says some other islands have customary prices especially the islands linked to a European country like the Netherlands Antilles, Guadeloupe and the British Virgin Islands: “I see overcharges occurring whenever the main clientele for the medical provider comes from tourism and when the provider has pretty much a monopoly. For example, Punta Cana and Puerto Plata in the Dominican Republic are areas where there are more tourists than locals and medical providers overcharge frequently – an aspirin can cost US$10 – not only do they overcharge, but they often ‘over-diagnose’, meaning they pretend the patient is sicker than he is and will do unnecessary tests and treatment.”
Parry of SCN agreed: “Our experience as cost-containers (not an assistance company) and therefore usually dealing with bills after they have been issued, is that with Caribbean medical providers overcharging, it seems to be prevalent in some areas while others, like the Bahamas and Bermuda, have not been a huge problem. Mexico on the other hand is a huge problem with inflated bills and often unnecessary treatments. Pro-active case management is, in my opinion, a necessity in these areas. When case management is not available, we have found that using an experienced medical negotiator (In our case we use Dr Colin Plotkin) can usually save considerable time, money and aggravation.”
Dr Jose Quesada, director of finance and operations for the International Medicine Institute of the University of Miami Health System, is also aware of the problem, telling ITIJ: “We understand this is a sensitive issue in healthcare worldwide. Transparency and competitiveness are our main goal when setting prices.”
There are some local assistance companies who pretend to be able to negotiate excessive bills, according to Ms Wolferman, but she admits she has not seen anything solid in relation to that yet: “I think we are better off being vigilant and talking to the providers directly.” Better prices tend to be where there is a large local population who will not accept inflated prices, she says.
The company has dealt with many unusual and frustrating cases: “We had a US nurse in Jamaica with appendicitis. She went to the hospital in Kingston which was appropriate for this type of procedure. Once there, she called us up to let us know she had a latex allergy and the hospital, a tertiary care facility, did not have any non-latex gloves. They could not touch her.”
Medex had to do an emergency air ambulance evacuation to Miami simply because of latex and the air ambulance company dispatched also had to make sure they had their latex allergy protocol in place: “We do offer a wide range of assistance, from the most simple situation, to the most critical.”
She says as a general rule the company needs to look at the healthcare facilities offered, uncover financial medical traps and make sure the quality of service offered is good enough for their members’ needs.
An assessment report from the Intergovernmental Panel on Climate Change shows the Caribbean region is in danger and that by around 2050, climate change is expected to reduce water resources on small islands – to the point where they become insufficient to meet demand during low rainfall periods. Sea levels are expected to rise and storm surges will affect vital local infrastructure and facilities. A leading paper in the Dominican Republic recently estimated that global warming could eliminate tourism as we know it by the middle of this century.
In 2002, in recognition of the need to mitigate the effects of natural hazards and disasters, the Caribbean Development Bank (CDB) established a Disaster Mitigation Facility for the Caribbean (DMFC), with financial assistance from the United States Agency for International Development. In April this year, the bank requested the financial experts should meet in Trinidad to discuss the possible global credit crisis and CDB reported that the Caribbean region was already experiencing a downturn in tourism.
So, aside from issues with healthcare facilities in the Caribbean basin, insurers will now also need to make sure they are aware of wider problems in terms of the global economy and climate change.