The planes glide in on a cushion of moist air rising from the Gulf Stream, casting fleeting shadows across Biscayne Bay, pointed toward the concrete at the 10th-busiest airport in the world.
The jets are carrying tourists to fill Miami's hotels, shoppers to fill its malls, businesspeople to fill its offices and banks.
More and more, they're ferrying patients to fill its hospitals.
Long an international center of finance, tourism and business services, this crossroads of the Caribbean and the three Americas is trying to diversify. It now wants to capture the flag as premier provider of medical services to the region and the world.
As in every place else in the U.S., Miami's hospitals are hurting, the inevitable consequence of a managed-care penetration of 70%.
"We have all these excess hospital beds," summarizes a hospital official who requested anonymity. "Why don't we fill them with sick South Americans?" Of Dade County's 9,720 licensed hospital beds, only 55% are occupied on a typical day. That means 4,374 are surplus capacity.
Dade County is 51% Hispanic, and in many places Spanish, not English, is the lingua franca. Radio stations broadcast in Haitian patois and Quebecois.
Visitors from Indiana may feel they've left the U.S. behind, but foreigners enjoy a high comfort factor here. It's got the language, the food, the culture and the climate. "They'd rather come to Miami than Boston or Baltimore," says Roberto C. Heros, M.D., a faculty member at University of Miami Medical School. "We can speak to them in Spanish."
Healthcare lure. Miami is trying to turn this multicultural atmosphere into an economic development tool. As part of a program of the Greater Miami Chamber of Commerce called "One Community, One Goal," nine of Miami's hospitals have teamed up in a coalition to promote international healthcare.
"We have identified seven industries that will be drivers of local growth over the next decade," says Jay Malina, an export financier and co-chair of the One Goal project. "These are all areas that can generate high employment growth for our people."
One of those industries is international commerce, which includes export of healthcare services.
For the first time, hospitals in Dade County have consented to work together on a strategic plan to draw foreign patients.
Martha Garantiva is the special consultant to the South Florida Hospital and Healthcare Association working on the international marketing effort. "Retail we do very well," she says. "People come here to shop. They go to Houston for medical care. That's what we want to change."
The international market offers a vast and growing reservoir of insured patients.
"If you look at that market down there, it's 300 million people. All we want is 5% of that," says Brian E. Keeley, president and chief executive officer of Miami-based Baptist Health Systems of South Florida.
"These are the top folks in each country, the ones with money," Garantiva says. "They will pay what it takes. They're very attractive patients for the hospitals and doctors."
Not only for providers. The chamber wants to increase the spillover of patients' pesos into other industries: hotels, taxis, retail, restaurants, entertainment.
The problem is, "there's no hard data," Garantiva says. "None whatsoever." She's taking surveys to find out "how many patients we are talking about, how much revenue, how are they getting here?"
The chamber's One Goal executive committee will hear preliminary results of the surveys this week.
Early returns indicate 15,000 foreign patients entered the nine One Goal hospitals last year. The physicians are seeing many more such patients who aren't being admitted.
The average acute-care patient spends $8,000 to $10,000 for hospitalization and physician services. Tertiary patients spend $20,000 to $25,000. So, estimated very conservatively, $120 million came into Miami hospitals from these international patients last year.
Garantiva adds, "The real number is going to be closer to 50,000" patients, once she factors in loose numbers for diagnostic services, second opinions and outpatient procedures. "That's the feel of what we think."
Dade County hospitals are so paranoid about giving away their trade secrets that they won't disclose what countries their patients come from. Her survey is limited to asking whether the patients are from South America, Central America, North America or Europe.
Hospital diplomacy. Traditionally, hospitals in South Florida have been so competitive they refused to say anything about their programs or to share information at all. Even today it's not uncommon to hear executives disparage the hospital across town in casual conversation.
The only way to get them to work together is to set up a neutral go-between whom all parties trust. The South Florida Hospital and Healthcare Association fills this role for the nine Dade County hospitals participating in the One Goal proj-ect. Those hospitals are Baptist Hospital of Miami; Columbia Aventura (Fla.) Hospital and Medical Center; Columbia Cedars Medical Center, Miami; Mercy Hospital, Miami; Miami Children's Hospital; Miami Heart Institute; Mount Sinai Medical Center, Miami Beach; South Miami Hospital; and University of Miami Hospital and Clinics/Jackson Memorial Hospital. Jackson Memorial is a University of Miami affiliate.
Three of those hospitals-Cedars, Miami Heart and Columbia Aventura-are owned by Columbia/HCA Healthcare Corp. Baptist and South Miami are part of Baptist Health Systems of South Florida.
Ten years ago the chamber tried to do something similar, Keeley remembers. "People sat around and growled at each other. That didn't go anywhere," he says.
In the meantime, other hospitals around the country have figured out that the international arena is the place to find the patients missing from their own back yards. Johns Hopkins Hospital in Baltimore, Stanford (Calif.) University Hospital and Methodist Hospital in Houston have all devised programs to serve a specific target market of foreign patients. Seattle hospitals are learning to be more appealing to Asians.
Now the attitude in Miami has changed.
"If we all are territorial and parochial and don't want to share, the global Miami will be the loser," says Davide M. Carbone, CEO of Columbia Aventura.
His organization has established a relationship with a hospital run by the Dole banana company for its employees in Honduras. That hospital was referring patients to Mayo Clinic in Rochester, Minn., or to facilities in Houston or New Orleans.
"But they have to fly through Miami" to get to those locations, Carbone observes. "We need to keep them here. That's what One Community, One Goal is about."
Interconnected. Carbone and everyone else in the Miami hospital scene describe an elaborate web of interconnecting affiliations-hospital to hospital, doctor to medical school professor, physician to patient, company to employee, employee to family-that siphons international patients toward Florida.
Heros, a neurosurgeon born in Cuba who taught at Harvard and the University of Minnesota, says taking care of Latin American patients is very different from taking care of Americans. "To them it's not a business transaction," he says. "It's very personal. In Latin America, if it doesn't go well, they say, `That doctor killed my father.'*" If it does go well, he says, a lifelong bond is formed.
Heros returned to his roots in Miami last year partly to recover that lost intimacy with his patients. Now he is director of the University of Miami's International Health Center, charged with building the patient base for the university faculty and its Jackson Memorial affiliate.
The International Health Center opened last October. Its goal is to attract 600 new foreign patients to the medical center every year.
"We're coming into this very late," Heros says. "The reason is complacency. Traditionally, among physicians the attitude has been, if you're excellent and well-known, the patients will come anyway."
At Jackson Memorial, as elsewhere, hard data are hard to come by. Nobody can say exactly how many foreign nationals have come through in recent years because no screening device existed to capture them in a database. Patients simply contacted their physicians, who admitted them, and then paid the bill and left. The university thinks 14,700 of its 787,000 medical encounters in 1996, or 2%, were international, but those aren't the same as hospital admissions.
The new program won't do any direct advertising or marketing to patients. The special market niche, Heros says, is not routine procedures but "quaternary medical care (the level of care beyond tertiary, including organ transplants) that can't be taken care of at home. There are lots of places in Latin America where a moderately complicated patient cannot be taken care of well." In other words, it's all about physician referrals.
The 600 physicians in the University of Miami faculty practice have positioned themselves to assume large risks, such as bundled pricing.
"For any diagnosis, any CPT code," Heros says, "we can quote over the telephone a single price. No outliers! I feel very proud to have jammed this down the throat of the medical administrators."
Trusting foreign docs. To make that work, the Miami doctors have to be able to rely on the diagnoses of the referring physicians in the home country. That means they need to know and trust those doctors.
Mercy Hospital was the first to welcome emigre doctors from Cuba after the revolution. It's been recruiting foreign patients on an organized basis for 15 years. Recently it combined its marketing program with Miami Children's.
With a patient base that's 75% Hispanic, Mercy's staff is largely bilingual. Together with Miami Children's, it publishes brochures for patients in English, Portuguese and Spanish. Mercy even offers a trilingual World Wide Web site at www.mercymiami.com.
Seamless service, or one-stop shopping, is the motto once patients and families get here, but the relationships with Latin American physicians are the synapses that have to fire to keep the program going.
Miami Children's offers pediatric residencies for students from 22 countries. With Mercy, each January the hospital hosts a post-graduate teleconference, beaming a signal to 7,000 physicians in 39 countries. During the teleconference, foreign doctors can send medical queries by fax, to be answered by a Miami specialist in real time.
Continuing medical education is another hook. The hospitals take physicians to conferences and send them around to give speeches and lectures. Miami Children's publishes International Pediatrics, a medical journal aimed at foreign doctors.
This outreach to physicians yields about 5,000 patients a year for the two hospitals. Less than 5% of the hospitals' gross revenues derives from foreigners.
Baptist, which reposes in Mediterranean splendor at the end of a double avenue of palm trees, is hoping its name and prestige within Miami reel in the foreigners. A relative latecomer to the international arena, Baptist has had to invest a considerable amount in infrastructure to handle these patients.
"We were known as the Anglo hospital and didn't have the Spanish language support system Mercy had," Baptist's Keeley says. But there aren't as many Anglo patients as there used to be-they've moved up to Broward County-so Baptist must adapt to the changing demographics, he says.
Baptist doesn't advertise but tries to build relationships. One of its coups is a $3.5 million contract to provide tertiary care to citizens of the Cayman Islands insured through the government. That accounts for about 40% of the international volume.
It has another contract with the Banco Centro Americano de Integracion Economica, based in Tegucigalpa, Honduras. Employees and dependents of the bank in Guatemala, Nicaragua, Panama and elsewhere come to Baptist. Because the bank is self-insured and handles its own billing, the hospital needn't worry about collecting from individuals.
Keeley reports that Baptist has about 3,000 international patients, generating $15 million in annual revenues. "But it's hard to track," he admits. "So many Latin Americans have Miami residences."
Baptist employs 10 full-time-equivalents in the international services department. The volume is accordingly high. The department gets about 120 phone inquiries a day and coordinates patients' medical care, transportation, hotel, family arrangements and other services.
Ana Bassil, a guest services representative, was born in Cuba of Lebanese parents. She speaks Spanish and French and understands Arabic. "Sometimes the family just wants to sit and talk," she says. "I will personally assure them they will be taken care of. I am the handholder, the psychologist, the sister, mother and friend."
This kind of personal service comes at a price. Fortunately, the Latin Americans in this income bracket can afford it, but they can be fussy and demanding.
"It's a difficult market," confirms Ana Roberto, a financial coordinator for international patients at Miami Children's. "They would like to know if the hospital will take them to a department store or to a restaurant."
Peace and prosperity. Miami hospitals and physicians wouldn't be in a position to grasp these opportunities if Latin America had not calmed down in the past 10 years. Political and economic reforms have consigned the turmoil of the 1970s-hyperinflation, disinvestment, insurgencies-firmly to the past.
Mature insurance markets can't develop without stable currencies. Now, a growing number of foreigners have health insurance that includes a rider for care in the U.S. There is also more direct contracting between U.S. providers and foreign governments, military forces and corporations.
Eugene Bajorinas, marketing director at Mercy, explains that Latin America has a total of 13 million to 14 million people in the wealthiest households of the major markets. "You only need a small portion of that business to do very well," he says.
As the middle class grows more confident and stable, those households will make demands for healthcare that their home countries can't meet. The country may have a social-security healthcare system that offers the basics, but access may be limited, or geographically remote, or there may be queues.
"Healthcare is less widely distributed in Latin America," says Bajorinas, who speaks French and Lithuanian and can read Portuguese and Spanish. In Brazil, for example, the disparities are enormous. Sao Paulo, the business capital, enjoys superb services, but in Rio de Janeiro access is difficult and the medical services are less advanced.
Recent improvements in transportation make Miami almost as accessible as Sao Paulo, he adds. "You could always get to Belo Horizonte (a city of 3 million in Brazil's interior), but you had to go to Rio first and sit in an airport three hours. Now there's a direct flight to Miami."
Structural changes in the U.S. also open new doors for Miami, says Sergio Gonzalez-Arias, M.D., a physician executive at Baptist. Thirty years ago technological advances were not disseminated as quickly or as widely as they are today. Now major hospitals all across the country have the capability to do advanced surgeries, not just the medical centers where the procedures were developed.
Wishful thinking? That's all very nice, but will it really harvest the volume of patients Miami's hospitals require? Isn't this marketing push the equivalent of rearranging the deck chairs at Pan American World Airways?
The sobering fact is, no matter how many foreign patients are lured to Miami, they won't fill all that superfluous capacity.
"The really empty beds in Dade County are not at the hospitals that are doing the marketing," says an industry insider who asked not to be identified. "The average half-empty community hospital in Dade County may or may not be any better than a major medical center hospital in South America or Canada" and therefore won't be in any position to attract these patients.
The industry observer thinks the chamber of commerce may be building sand castles. "The chamber thinks this is employment development," she comments. "The hospitals think of it as employment retention. They hope they won't have to lay people off."
"It's incremental income," Keeley freely admits. The hospitals' fixed costs are covered. The foreign patients add variable costs but pay top dollar. "It's an extremely prudent, very logical response to our local marketplace. Plus, it's a lot of fun."
Also, there have been public relations disasters. Physicians at the University of Miami, with motives of pure charity, treat impoverished foreign patients who show up there. Unfortunately, the days and weeks of hospital treatment these patients get in Jackson Memorial go on the tab of Dade County taxpayers, who directly subsidize the county hospital.
Even the mission of international medical education can go askew. Heros worries that too many medical students and residents from abroad are staying in the U.S. At one program in Miami for internal medicine, "60% go back, 40% stay. We need to get that up to 100% so they go back to Latin America and elevate the level of medicine there," he says.
Still, one could argue that the Miami effort represents the spirit of U.S. healthcare entrepreneurship at its best: dreaming up new means of financing and delivering better medical care to ever more people.
Bajorinas sees a rising middle class south of the Tropic of Cancer creating vast opportunities in healthcare. Today, strengthened partnerships; tomorrow, joint ventures-and more. Technical support, management consulting, affiliations, ambulatory clinics, managed care, telemedicine. Who knows? U.S. hospitals and physicians and assorted deep thinkers could figure out how to leapfrog the antiquated healthcare infrastructure in Latin America and the Caribbean and jump straight into the 21st century, much as telecommunications technology has done in many underdeveloped countries.
Why shouldn't Miami lead the way?