With pressure growing on hospital systems to find new sources of revenue, many healthcare executives are turning to international patients as an attractive option.

A substantial number of overseas patients are willing and able to come to the U.S. for diagnosis and treatment. They typically are patients with more complex disorders from countries where high-level specialty care may not be readily available. More importantly, they can afford to pay for their care out of pocket or have their care fully funded by their governments or private insurance.

It's a tempting business. But revenue is only part of the picture. Any healthcare executive who starts with dollar signs dancing in their eyes is in for a shock. The real challenge in establishing a thriving international patient business is modifying some, if not most, aspects of a hospital's basic infrastructure.

Some of the hospital systems that have succeeded in this market, including Cleveland Clinic, Mayo Clinic and Johns Hopkins Medicine, had the large advantage of international name recognition. Yet even they struggled to meet the unique demands and realities of serving this nontraditional market.

Serving international patients eventually turned out to be profitable for Johns Hopkins, where I work. But we had to invest millions of dollars in the early years in staffing, program development and marketing.

Here are some of the hurdles that hospital systems will face in caring for international patients and some of the approaches Johns Hopkins Medicine took to get over them:

• Language. Now that the ability to accommodate non-English-speaking patients is part of the Joint Commission accreditation process, U.S. hospitals are learning how expensive and tricky providing translation services can be. The challenges are multiplied when trying to serve a number of international patients, whose languages and dialects may be more varied than those normally encountered; who frequently have little experience coping with a language barrier; and who may not have family and friends around to lend support.
  
  Johns Hopkins has a small army of interpreters on tap, but found even that's not enough to ensure a good patient experience. While interpretation creates a temporary bridge between patient and caregiver, a stronger healthcare partnership is formed when the caregiver speaks the patient's language. For that reason, we increased hiring of physicians, nurses and administrative staff who speak other languages, and supported language training for those willing to learn.


• Culture. Almost every basic assumption clinicians and administrators make about how to manage patient care goes out the window when working with patients from other countries. Among the challenges Johns Hopkins routinely encounters: patients who come from cultures where its people routinely arrive hours late for appointments yet expect immediate attention; patients who prefer that clinicians address all comments and leave all decisions to husbands or parents or even young male children; patients who won't remove clothing for exams; and much more.
  
  Insisting that patients and their families do things “our way” is a nonstarter. Though it often takes creativity to do it, Johns Hopkins found there are always ways to respectfully accommodate cultural expectations without compromising the delivery of top-notch care or violating ethical standards.


• Logistics. Routine processes such as scheduling tests, getting a patient into a convalescent facility and arranging for post-discharge care can all become nightmares when dealing with a patient who can stay in the U.S. for only a relatively short time. We developed special appointment-making processes designed to accommodate the compressed schedules and uncertain needs of these patients, and studied the workings of healthcare systems in dozens of countries so that we can smoothly transition our patients into appropriate follow-up care, complete with medical records.
  
  Then there are travel arrangements for patients and lodging for family and post-discharge patients. Patients often won't travel to a hospital that won't take care of these logistics. The job can be outsourced, but few outside firms have the ability to closely coordinate with a complicated and often rapidly changing medical schedule. It took in-house travel experts to make sure it was done right.

Thompson

Billing. Overseas patients and payers will shop around—and expect rapid financial estimates and consolidated billing for the entire experience. That includes not only all physician, medication, lab and facilities costs, but often travel costs and convalescent and follow-up care. Tying it all together can be laborious and requires some expertise as well as specialized software. Meanwhile, collecting from overseas payers is typically a unique process in every country and generally very different from the U.S. Learning the ins and outs takes time and effort, and revenue will be diminished while doing so.

Marketing. Yes, marketing is part of the puzzle, too. This isn't a “build it and they will come” proposition. International brand awareness, reputation and partnerships must be carefully and patiently nurtured, region by region. One way Johns Hopkins got up to speed was by sending a number of key executives and clinical leaders to healthcare conferences all over the world, making contacts and asking a lot of questions. There were no shortcuts; it took years.

Even hospitals that are up to the marketing challenges will be better off if they focus first on providing good service to a small number of overseas patients and slowly build the institution's word-of-mouth reputation. Striving to bring in a flood of patients right away will only create patient-experience disasters that will permanently damage a hospital's global reputation.

Steven J. Thompson is CEO of Johns Hopkins Medicine International and senior vice president of Johns Hopkins Medicine, Baltimore.