Monday, January 01, 2018

Medical Migration? Medical Tourism? Medical Exile? Whaaaaaa?

Three random topics.    Or    so    I    thought.

1. Medical Migration?  A former employee of the Johns Hopkins Health System has accused the System of violating state and federal regulation by admitting out-of-state patients in preference to Maryland residents.  In other words, the Hospital is “migrating” out-of-state patients into Maryland.

Maryland sets an annual global budget for each of its hospitals.  The federal government also participates in the regulations, by requiring that the hospitals comply with the state-set budgets.  I suppose the feds’ interest is that they finance Medicare and share in the financing of Medicaid.  But the global budgets apply only to residents of Maryland.  Hospital revenues from out-of-state patients – “medical migrants” - are outside the global budgets and thus produce unregulated additional revenues for the hospitals. 

Hopkins’ former employee alleges Hospital management pressured staff to migrate out-of-state patients into Hopkins Hospital, taking beds that might otherwise have been available to Maryland residents, and generating revenues that Maryland residents would not have generated.  Hopkins has responded that “Our census shows that the majority of our patients are from Maryland and that the number has steadily increased over the past several years” - which is fine as far as it goes, but does not directly or fully answer the issue.  A judge will have to sort all this out.

2.  Medical Tourism?  This term describes a growing international trend among patients seeking medical care outside their own country. It has been a recurring topic at InsureBlog over the past few years - here is an old post from 2007; there are many others. 

Medical migration is similar to medical tourism because both have similar motivations and similar ends:  the unbreakable linkage between money and medical care, and access to medical care that may not be locally available. The Johns Hopkins situation is not exactly medical tourism because it involves movement between states in the same country, not between two different countries. Yet it may be evidence that U.S. patients are becoming more willing to travel for their medical care.   And, of course, it’s also evidence of hospitals’ continuing creative efforts to improve their revenues.  

 What’s that?  Scotland is “exiling” certain patients to other countries in the U.K. for medical treatment? 

It’s complicated.  It seems Scotland has allowed at least 460 NHS specialist positions (plus an additional unspecified number of nurse positions) to go unstaffed.  As a result, a growing number of Scottish patients face unexpected travel for specialist or routine nursing care.  NHS Scotland is sending these patients to England, Wales, or Northern Ireland.  NHS actually anticipated this as an infrequent contingency, so there are funding and administrative means in place to handle referrals.  But the recent, sharply increasing volume of such referrals was not anticipated.  Scotland has apparently been managing – or mismanaging - its understaffing problem by “exiling” patients to obtain care outside their own country, rather than filling the vacant specialist positions inside Scotland.  

The available information is hard to interpret.  For example, how does Scotland reimburse other U.K. specialists?  How does the sum of those reimbursements compare to the sum of the salaries and other employment costs for the 460 specialists the Scots would otherwise employ?  I can’t help but suspect one of those numbers is a fair bit larger than the other.

So why tie these three phenomena together?  Movement. 

Specifically, the movement of a growing number of patients willing - or obliged - to travel far from where they live, in order to access medical care.  Movement of patients within the U.S. to access medical care has been a  slow-growing thing for some years.  But in other parts of the world, such patient movement seems to be growing faster, and is more common across national borders.  And the worldwide phenomenon is not exclusively physician- or patient-driven. Governments are facilitating and, in some cases (i.e. Scotland), are requiring such travel. 

Is patient movement likely to improve care? Will it improve access? Balance patient loads? Result in better match of patient needs with services across local, national, and international medical care delivery systems?  Or will it be not so beneficial?  Will these trends instead end up exposing a world delivery system largely unprepared to meet the rising demand for medical care? Is this the start of some classic B-movie, in which a flooding river causes the dam to spring small leaks, as rising waters spill around and over the dam, and no one is listening to the few townspeople who notice what is happening?

Time will tell.  Meanwhile these phenomena are related, and do bear watching.
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