Most major hospitals and academic medical centers in the U.S. have developed a strong business in diagnosing and treating international patients. But now more of these systems are turning their attention to collaborating with overseas institutions to advance healthcare abroad and strengthen health infrastructure and access. “Collaborations go hand-in-hand with international patients,” says Ruth Frey, senior director of International Business and Program Development at the Children's Hospital of Philadelphia (CHOP). “To be a good partner in a foreign country, having international patients alone isn’t enough.”
It’s not that the international-patient business isn’t strong. A 2010 study published in the journal Health Policy suggested the number of inbound patients each year ranged from 43,000 to 103,000. In a 2015 U.S. International Trade Commission report, estimates of the number of air travelers who listed health treatment as the reason for visiting the U.S. between 2003 and 2013 ranged between 100,000 and 200,000 annually. In 2015, according to the U.S. Cooperative for International Patient Programs (USCIPP) — an umbrella organization for nearly 70 hospitals and academic medical centers in the U.S. participating in international healthcare services — international patients who traveled to the U.S. for healthcare spent more than US$3.5 billion — an increase of nearly 25 percent since 2010.
But while the flow of patients entering the U.S. for healthcare shows no immediate signs of abating, economic changes in the traditional source markets for medical travelers are shifting the demographics of the patient pool. Wealthy countries, especially those in the Middle East, are dispatching fewer patients to the U.S. for treatment. “Sending patients to the U.S. for care is expensive,” says Frey. “Some countries are now more budget conscious, and healthcare is one of the areas where they are cutting back.”
Instead, many foreign governments are redirecting healthcare expenditures toward building the skills and infrastructure necessary to treat their citizens at home while also attracting more foreign patients. “What has evolved over the past 20 years is that there are now world-class institutions around the globe delivering cutting-edge quality healthcare, and they’re doing it better, faster and cheaper than we can do it in the U.S.,” says Robert Crone, vice dean for Clinical and Faculty Affairs at the Weill Cornell Medicine – Qatar medical school (WCM-Q), a joint venture between Cornell University and the Qatar Foundation, a nonprofit foundation that funds educational and healthcare initiatives in Qatar.
WCM-Q came out of a growing need internationally to provide more and better-trained healthcare staff. “In order for overseas healthcare systems to grow, they need well-trained, high quality clinicians, and many are starting their own schools to train them,” says Crone. Founded 15 years ago, WCM-Q is one of four international academic outreach initiatives at Weill Cornell. With more than 500 resident faculty members and an enrollment of nearly 300 students, WCM-Q’s class of 2017 recently graduated 50 fourth-year medical students. But Crone believes more and more international partnerships are likely to move beyond education. “Creating partnerships around human resource development is really the next big opportunity for U.S. institutions,” he says.
Delivering superior healthcare requires expertise, which creates opportunities for international partnerships. “In specialties like heart, cancer, and orthopedics, many countries are equal to the U.S in terms of providing good quality healthcare,” says Laura Robbins, Senior Vice President of Global & Academic Affairs at the Hospital for Special Surgery (HSS) in New York City. “But others are lagging behind, so they’re reaching out to experts for help.”
Although a few organizations have joint ventures where they have “bricks on the ground” in other countries, such as the Cleveland Clinic Abu Dhabi, the sharing of knowledge and information between institutions forms the foundation of most international collaborations. “The majority have, at a minimum, educational and research partnerships,” says Andrew Garman, CEO for the National Center for Healthcare Leadership, and executive director of USCIPP. “A small portion has a fuller portfolio, which could include formal education programs, such as degree programs and management consulting agreements of varying kinds.”
HSS takes two approaches to international partnerships. One is the continuing education program offered by its HSS eAcademy, a digital learning platform for healthcare professionals. “Our education programs are available in 154 countries around the world,” says Robbins. “We train mostly surgeons, other physicians, and physical therapists.” During a recent exchange program with China, more than 3,600 Chinese physicians participated in training via live-video conferencing.
The second is HSS’ Global Orthopedic Alliance, through which HSS guides institutions in Brazil and South Korea toward meeting established benchmarks. “We help hospitals improve their clinical outcomes and improve their operations and systems within the hospitals,” says Robbins. “That includes everything from helping them restructure their organizations and evaluate their staffing patterns, to assessing how they outfit their operating rooms so they can provide better surgeries.”
The collaborations also provide a means for HSS to enhance its reputation abroad while expanding its mission. “Many healthcare organizations around the world want to partner with well-established academic centers,” says Robbins. “It’s about patient care, but it’s also about marrying that with the education and research missions, which goes toward providing the best care possible for patients.” The hospital seeks out institutions with the same values and mission, so they’re more likely to develop into long-term relationships. “We created our alliances to be strategic,” Robbins explains. “Prior to that, we were being very reactionary.”
The unique training and educational needs of foreign specialty providers, such as pediatricians, drive the formation of many international partnerships. “Although many countries have pediatric providers, very few are subspecialists in areas like pulmonary or oncology,” says Frey. To meet this need, CHOP, which partners with a dozen foreign healthcare organizations, sends between 25 and 50 pediatric experts abroad each year to evaluate and follow up on patients and participate in teaching rounds and lectures. Frey estimates that the extensive overseas training provided by CHOP affects the lives of as many as 1,500 children yearly.
One of the most challenging aspects of preserving international partnerships is maintaining trust and a strong level of commitment, coupled with a high degree of cultural sensitivity, says Frey. The lion’s share of Frey’s time is devoted to spending time in other countries cultivating relationships and identifying ways in which CHOP can better serve their collaborating partners. In a recent initiative, CHOP nurses travel abroad to learn about partnering countries’ cultures in a foreign hospital-based immersion program. “This is the sort of thing that will keep us in good light with these countries,” says Frey.
Being seen in a good light via collaborations is likely to become increasingly important to some U.S. hospitals' bottom lines. "Some countries are now looking to use preferred providers," says Frey. "They’re not only looking for the ability to send sick children to the U.S., but they’re asking, 'What are you doing for us in terms of education and research?'" A lot of hospitals are going to find themselves left off the preferred list, Frey adds. The volume of international patients seen at HSS, on the other hand, suggests that international collaborations can help guard a spot on that list. In 2016, HSS saw 1,200 international patients, up nearly 10 percent over the previous year — an annual trend they have experienced for the past four years.
The partnerships aren’t risk-free, however. “We’ve had some unsuccessful operations,” admits Frey. “When governments don’t have the finances to see a project through to completion or don’t realize the efforts that go into building a children’s hospital, that’s risky.”
While the dividends of partnerships are manifold, the directors of most international collaboration programs agree that one of the greatest benefits is a kind of “reverse innovation” where they receive more from their partners than they give. “That probably happens every day,” says Frey. “We’ve made diagnoses and written papers about diseases that we didn’t even know existed.”
— Teresa L. Johnson
Teresa L. Johnson is a freelance writer based in Woodbridge, Virginia.
Editors’ note: GHCi previously published a short excerpt from this article. This full version is being published here for the first time.