HOSPITALITY RISKBRIEF

Guest Turned Patient: Medical and the Industry

Medical Tourism within the U.S. and abroad is a multi-billion dollar industry set to continue steady growth as people around the world become more accustomed to traveling for health care. For the , challenges arise with drawing the line between expectations for medical care and expectations for the hotel industry. From wellness programs at spas and to joint venture projects between health care providers and hotel chains, “” takes many forms. Estimates for the size of the market vary anywhere from $10 billion to in excess of $50 billion , depending on what is included in the definition. Related “” could be worth 10x that amount. i The number of visitors is also substantial. The Texas Medical Center draws 20,000 international medical tourists annually to Houston; ii on the other end of the spectrum, Chinese citizens took an estimated 500,000 trips abroad for medical treatment in 2016. iii The various segments carry different types of risks for the hospitality industry, sliding along a scale of how much a hotel plans to provide for guests, as well as what guests expect from the hotel.

Wellness Tourism The concept of “wellness tourism” falls in line with guest expectations for continuing a healthy lifestyle while they , whether for business or leisure. In the beginning, could meet this demand with a few treadmills in a little-used corner of the hotel next to the chlorine aromas of the indoor pool. Over time this concept has grown to full-fledged gyms, spas offering massages and facials, and all varieties of personal training and special meals to add to the guest’s wellness experience. This even spreads to the guest rooms, with many hotels offering hypoallergenic spaces. There are two different categories of wellness tourism to consider: • Primary Wellness Tourists : Wellness is the sole purpose or motivating factor for the trip or destination choice. These tourists account for 13% of wellness tourism trips and 16% of expenditures. • Secondary Wellness Tourists: Seek to maintain their wellness or participate in wellness experiences while taking any kind of trip. Accounts for the significant majority of wellness tourism trips (87%) and expenditures (84%). iv

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Client Risk Solutions

With increasing demand, the hospitality industry has encouraged guest expectations for a healthy environment and hotel staff’s attention to wellness. The types of risks that arise from a wellness initiative are fairly traditional. While yes, there may be some novel scenarios considering the toxic nature of a facial scrub or personal trainer liability, most new amenities offered are not so outside the realm of what can be expected at a hotel. Therein lies a distinction between wellness tourism and medical tourism: the guest is still expecting the hotel to act like a hotel. “Wellness” may be somewhat of a misnomer – guests aren’t looking for a cure as at the mineral springs of old. They’re just looking for a more healthful . The danger of a hotel being a part of providing the cure comes into play in medical tourism, however. There, a guest may expect the hotel to act like a hospital.

Medical Tourism Medical Tourism conjures up images of a beach-side plastic clinic on a tropical island, with a frozen drink in a coconut to go along with the IV drip. While you may be able to find this, a fair definition of medical tourism is any travel for any type of medical care. While often recognized as traveling from the U.S. to other countries, it includes all measures of domestic and international travel. Certain medical centers have earned international reputations for excellence, and U.S. patients looking for the best care will seek out these facilities domestically. For example someone from the Midwest may travel to Johns Hopkins in Baltimore or Sloan Kettering in New York City for cancer care; someone in the Northwest may travel to the in Minnesota for treatment of a rare infectious disease. Within Texas and the border region, many travel to the Texas Medical Center in Houston for all types of care. What makes a medical tourism destination? The quality of care is certainly a factor, as are specialized service and advanced technology. But other important factors may include a better price point or faster care than at home (particularly so when we consider international medical tourism). And for many, the overall attractiveness of the location plays a role, including factors like (a) a positive environment for convalescence (e.g., beachside cabana); (b) existing tourism infrastructure; and/or (c) convenience to airports and other mass transit.

Governments and independent regulatory and trade group bodies recognize industry growth. There are evolving medical tourism guidelines and international accreditation, including from the Global Healthcare Accreditation Program. v From a broader policy perspective, states and municipalities have started to recognize the importance of the health care industry for the local economy. In many cities the hospital system may be the largest employer. To build on this, certain hubs have invested in and actively market their health care centers. The idea is simple: the more business the hospitals do, the more tourist dollars flow into the local economy as a whole: , shops, and, certainly, hotels.

The Hospitality Model: Define Your Role Hotels have a role to play in the growing medical tourism industry whether they want to or not: people traveling for medical care need a place to stay. A property should determine if it wants to be an active or passive player and where to draw distinctions so that guests have proper expectations.

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Client Risk Solutions

Where a hotel does not market itself to medical tourists, it may still be passively involved given a simple rule: location. Hotels in close proximity to hospitals will have guests staying in the hotel to be closer to the hospital, whether as a patient before or after treatment or as a visitor. “Passive” can mean “willful blindness” – a property close to a health care facility can determine without much trouble that a significant percentage of its guests are connected to the hospital rather than college students on spring break.

Passive can give way to active participation with something as simple as a discount provided to patients or guests of patients. By providing the discount, the property is marketing to that potentially vulnerable group of guests. There are more involved ways a hotel can become embedded with the medical facility: • Special transportation and concierge services, including an on-duty nurse for guests. • Sharing physical space, where the hospital turns over part of its space to a hotel (or vice- versa). For example, the hotel spa offers wellness services for recovering patients. • A dedicated mixed-use project, where by contract or even by shared financing the hotel and medical facility are intertwined from the ground up. Perhaps the hotel and hospital share a main lobby, and security understands how to shift traffic appropriately. • A more intertwined model, where for example instead of discharging a patient the hospital transfers the patient out of recovery and into a room on the convalescent floor of the hotel.

What’s the Harm? More market opportunities are normally better than less. Thus if there is a potential pool of guests that just happen to be coming from or leaving the hospital hotels may wish to attract those guests to their property. The challenge becomes distinguishing the guest from the patient, in the hotel staff’s mind and in the guest’s mind. It is important to understand because the medical tourist is more vulnerable than a wellness tourist or a generic tourist. While those latter two categories have certain expectations, a medical tourist particularly post-procedure calls for more attention to well- being. There are many different scenarios of how a hotel could get into trouble. These are just a few: • Scenario 1: A hotel provides a free shuttle to and from the hospital a quarter mile away. The shuttle bus does not have the “kneeling” function that would otherwise allow a bus to descend to curb level for disembarking. As a result, a patient/guest recovering from ACL surgery cannot easily step off the bus, falls and injures her other leg. • Scenario 2: Housekeeping enters a room to make it up. A patient/guest recovering from surgery is in the room, confined to a bed. He says his wife stepped out and asks the housekeeper to get a bottle of pain medication from the bathroom. The housekeeper does so, fishing out two pills for him. It turned out the man had already taken his prescribed dose and the extra medication sends him into shock. • Scenario 3: A patient/guest is recovering from eye surgery. She tells the hotel that her eyes are bothering her and asks for the nurse on staff. The nurse examines her and sends her to the local partner hospital, not the specialized facility where the patient/guest had undergone eye surgery. The local hospital, unfamiliar with the patient or the procedure, misdiagnoses and mistreats, rendering the woman blind in one eye.

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Client Risk Solutions

• Scenario 4: A guest arrives to take a room with the discounted hotel patient rate. The hotel supplies a non-ADA-compliant room. The guest struggles to climb into the tub, falls, and suffers a head injury. • Scenario 5: A housekeeper bypasses a room with the Do Not Disturb sign. The housekeeper did not know the guest requested check-ins every four hours per doctor’s suggestion. Inside, the guest had fallen out of bed and lacked the energy to get up or call for help.

Risk Manager Checklist There are ways to capitalize on the economic opportunities of a growing medical tourism industry while still protecting your property. • Set Expectations: This begins with proper terminology. The hospital has patients – you have guests. Stay away from “medical” or “treatment” or “recovery.” • Life Safety Review: Understand the vulnerable nature of medical tourists when it comes to mobility. Typical evacuation plans may not be practical, thus explore better shelter-in-place options for power outages, tornadoes, or active shooter incidents. • Staff Guidelines & Training: Be clear with all staff, and particularly housekeepers and others who may enter rooms, regarding what they can and cannot do. Providing hospitality is one thing; providing healthcare is another. Help your staff understand the difference. Train on the dangers of blood borne pathogens and personal protective equipment and related risks like needle stick exposure. Set practical policies on Do Not Disturb signs and other guest requests. • ADA Compliance: It is always importance to comply with federal and state disability accessibility and accommodation regulations. A property may need to go a step further when it knows a significant portion of its guests may need accessibility assistance (automatic doors that stay open longer and close slower; fewer stairs and more ramps). • Shuttle Service: If you provide shuttle service to/from a nearby health care facility, set limits and train accordingly. Wheelchair bound guests may require properly trained or certified drivers. Set expectations that the shuttle is not an ambulance and the drivers are not EMTs. If the shuttle is not part of the hotel, have clear signs and other messaging so there is no apparent agency. • Spa Treatments: Assure compliance with municipal and state laws regarding types of treatment and necessary licenses. Be sure any invasive procedures stay within those guidelines and do not go over the line to medical treatment. And have clear messaging distinguishing spa treatments from physical therapy. • On-Site Clinics and Directing Care: If you provide a clinic or on-site nurse, clearly spell out the individual’s role. If a guest gets any medical care at all have the guest sign a waiver acknowledging the limits on treatment. • Contracts and Insurance Coverage: If you enter into a contract with a health care facility understand the rights and responsibilities. Expressly state who is responsible for what – especially if hospital staff will provide care in the hotel, but also if they will not so that you and your team understand responsibilities once the patient is discharged to your facility. Include indemnity provisions putting liability for inadequate care on the hospital, and clauses for insurance procurement and certificates of insurance.

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Client Risk Solutions

Conclusion Any industry with the potential for growth in the hundreds of billions of dollars deserves attention. Hotels would be wise to keep in mind that medical tourists can make for vulnerable guests. Understand the risks, and set expectations about what the property will provide.

AIG’s Client Risk Solutions and Retail, Real Estate, and Hospitality Practice Group stand ready to help your institution manage risk. For more information on Client Risk Solutions, contact [email protected] or visit: • Client Risk Solutions www.aig.com/crs

References

i Estimates for the medical tourism industry vary widely depending on which factors are used and estimate parameters set by the measuring government body, trade group or other organization. For reference, see, e.g.: Global Wellness Institute, Global Wellness Economy Monitor, January 2017 (see https://www.globalwellnessinstitute.org/industry-research/ ); and the International Medical Travel Journal, which highlighted discrepancies in estimates in a 22 August 2016 report (see https://www.imtj.com/ ). While it does not supply figures, the U.S. CDC provides citizens guidance on medical tourism generally (see https://www.cdc.gov/features/medicaltourism/ ). ii See, e.g., Lora Hines, International Patients Boost Houston’s Medical Economy , Houston Chronicle (August 9, 2014). iii See, e.g., Sui-Lee Wee, China’s Ill, and Wealthy, Look Abroad for Medical Treatment , New York Times (May 29, 2017). iv Global Wellness Institute, Statistics and Facts, Wellness Tourism Defined (available at https://www.globalwellnessinstitute.org/press-room/statistics-and-facts/) v The Global Health Accreditation® Program is the first accrediting body focused on medical travel services and the medical travel patient experience. It complements existing national and international accreditation programs which tend to focus more on clinical aspects of care. AIG’s Aileen Killen, RN, PhD, CPPS, is on the inaugural advisory board. See http://globalhealthcareaccreditation.com/ for more details.

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