In early September, the Nashville Health Care Council was busy preparing for its third annual international trade mission, a trip for area healthcare executives seeking business opportunities in Europe. Last year, the group traveled to France and Spain to talk with key industry and government leaders, and this year the 37 participating executives were headed to Belgium and Italy.
That all changed Sept. 11. In the days after the terrorist attacks, the council decided to postpone the trip abroad indefinitely.
Very few American hospital companies have ongoing business dealings with areas that have become international hot spots in the wake of the terrorist attacks and the subsequent U.S. response in Afghanistan, but several have tangential or growing operations in Europe. Those that do have ties to the Middle East and even Europe, however, say that it's difficult to determine the long-term effects the tightening of travel security, the war in Afghanistan and the shifting sands of global politics will have on American ventures abroad.
Jack Bovender, president and chief executive officer of HCA, the nation's largest for-profit hospital chain, was to have led the Nashville delegation, which would have met this week with the U.S. ambassador to the European Union, the Italian minister of health and top European Union officials.
"We at the staff level got together with Jack Bovender and made the decision," says Matthew Gallivan, president of the council. "There's always the risk that if things heat up on you or there are surprises, that government offices could close down. And there are broader security concerns as well."
The council still plans to reschedule the trip at some point, he says.
One healthcare company that routinely works in the Middle East is HCCA International, primarily a consulting and healthcare recruitment firm. The Nashville-based company's Internet home page, with its photo of a man wearing traditional Arab attire and a silhouette of two camels, portrays working as a healthcare professional in the Middle East as a ticket to adventure and excitement. The company has in the past helped start up and manage a number of hospitals in the region (May 7, p. 30). HCCA recruits healthcare professionals for hospitals overseas and also brings healthcare professionals from abroad to clients in the U.S. Its clients include the King Faisal Specialist Hospital and Research Centre in Riyadh, Saudi Arabia; an affiliated King Faisal Specialist Hospital in Jeddah; the King Khaled Eye Specialist Hospital in Riyadh; and the Shaikh Khalifa Medical Center in Abu Dhabi, United Arab Emirates.
"One of the things that anybody who dedicates their business strategy to international knows is that you have to be extremely fluid," says Karen Fleming, HCCA's vice president of client services.
The company's founder, Ronald Marston, was in Saudi Arabia and the United Arab Emirates last week on a mission to reassure the company's client hospitals that the U.S. war against terrorism has not changed American perceptions about the Muslim world.
Still, it has become a harder sell to get U.S. employees to leave American soil, she says.
"The events of September 11 have impacted recruitment from North America to the Middle East, and I think it's understandable," Fleming says. "We've had people we've been talking with who have decided to postpone going over there until things calm down a bit."
In addition, HCCA has yet to hear about a consulting contract it bid on-for a hospital Fleming declined to name-in the Middle East. The decision on the contract was supposed to be made by Sept. 15.
"They've postponed the decision," she says. "They need to take a deep breath and figure out where things are going."
Fleming says many hospital companies have shied away from the Middle East since the early 1980s, simply because of the risks and uncertainties in doing business there, which include reimbursement lag times and upfront costs, as well as cultural challenges. U.S. companies also have had their hands full getting their domestic operations in order.
However, HealthSouth Corp., a Birmingham, Ala.-based operator of rehabilitation hospitals and ambulatory surgery centers, last fall signed a contract to build and manage a large rehabilitation hospital in Saudi Arabia. The hospital, 450-bed Sultan Bin Abdulaziz City for Humanitarian Services, is under construction north of Riyadh and is expected to open early next year, says Richard Scrushy, HealthSouth's chairman and CEO. HealthSouth also has facilities in Australia, Canada, Puerto Rico and the United Kingdom.
"We obviously are concerned for our people going back and forth," he says. "But if you were to ask me would I do it again, I'd say I would. It's a good contract for our company."
Several American hospital companies have established beachheads in Europe, where the healthcare industry has more in common with the American system. Universal Health Services, King of Prussia, Pa., which owns or leases 23 acute-care hospitals and 37 behavioral hospitals in the U.S., earlier this year acquired an 80% stake in a French hospital company, Medi-Partenaires. Last month, that company bought its ninth hospital in France, a 205-bed facility in Toulouse.
"I don't think the events of the past several weeks have changed our desire to invest in France," says Kirk Gorman, UHS' senior vice president and chief financial officer.
Gorman says the company's short-term strategy does not include expanding overseas beyond France, despite solicitations UHS has received from the Middle East and Asia to consult on hospital projects.
"Part of running a business is picking or choosing where you think you can perform well," Gorman says. "Each layer of change in cultural underpinnings just adds another layer of risk or complexity."
The reverberations of Sept. 11 have also been felt at hospitals on U.S. soil that have programs that bring foreign patients here. At Methodist Hospital in Houston, between 3% and 5% of patients are international, with about half of those coming from Latin America and the remainder from across the globe, including many from the Middle East. Many patients come for complicated tertiary care, including cardiac procedures, cancer treatment and organ transplants.
"For the first three or four weeks afterward, we saw a 20% decrease in patients coming from the Middle East," says Danielle Rizk, vice president of international services at Methodist.
Rizk, who is Lebanese, says many of her employees are Middle Eastern, and many of the patients wear traditional Arab dress.
"There was a lot of fear that there would be a backlash," she says. "Our head of human resources sent a very strong letter to the organization about doing the right thing, talking specifically about the aftermath of this terrorist attack and how we needed to be sensitive to people from that part of the world who had not done anything."