Sanford Health, a nonprofit health system based in Sioux Falls, South Dakota, will continue to expand its operations internationally, said Dr. Luis Garcia, president of the Sanford Clinic division. Sanford said in 2018 it would expand to Costa Rica, Ireland, New Zealand, South Africa and Vietnam, and those projects are still in the works and on track despite the COVID-19 disruption, a spokesman said. It operates in nine countries, including China, Germany and Ghana.

Sanford’s international relationships have provided a buffer during ongoing staffing shortages, allowing it to draw from labor pipelines around the world while also sending its own residents abroad, Garcia said.

“We have always said that it is important for us to grow our own. For our American residents, it’s a plus that they have international experience, but for those coming here it provides an exposure to the Sanford culture,” he said. “Even if they come as a local for two or three months in highly demanded medical fields such as rheumatology and dermatology, which fills the need we have.”

While health systems’ international footprints helped providers cope with staffing shortages, the decline in lucrative medical tourism revenue depletes capital project funding, service improvements and charity care investments, Vequist said. Roughly $200 billion allocated through the COVID-19 Provider Assistance Fund has cushioned the blow from lost medical tourism revenue, but that funding is dwindling, economists said.

“It was such a banner year in 2019 for medical tourism, and then of course we had this downturn because of COVID,” said Vequist, who analyzed data from the U.S. Bureau of Economic Analysis, the International Trade Administration and the Transportation Security. “For hospitals, medical tourism offers wonderful margins as treatment is almost always paid in cash.”

The number of international patients treated at the Cleveland Clinic was halved, falling from 9,150 in 2019 to 4,939 in 2020. The volume increased to 7,686 patients in 2021.

“Obviously, the pandemic did no one any favors in terms of travel and health care,” said Dr. Curtis Rimmerman, Cleveland Clinic’s president of international operations. “We quickly realized that our priority was to take care of local COVID patients. But things have calmed down and volumes have recovered significantly in Florida and Northeast Ohio as air travel reopens.”

Health systems have steadily increased their marketing budgets targeting out-of-state patients. Sanford, for example, recently began a partnership with the Manitoba government in Winnipeg, Canada, where there are a large number of neurosurgical patients being sent to Sanford, Garcia said.

“The idea is, over time, we start to strengthen the relationship,” he said. “For us, it’s a great opportunity to help with the backlog that the Canadian government has for certain services.”

Mayo Clinic, Cedars-Sinai, Johns Hopkins Medicine, MD Anderson, Sanford and Cleveland Clinic are among the many health systems that attract patients from the Caribbean, Latin America, Europe, Canada, the Middle East and Central America.

Many residents of Latin America and the Caribbean travel to Florida for care at Cleveland Clinic’s network of five hospitals in the state. The network offers heart, vascular, thoracic, digestive, urology and transplant care for adults and children, Rimmerman said.

“There is a cultural comfort zone for some of these patients (in Florida),” he said.

The Cleveland Clinic also has facilities in Toronto, Abu Dhabi and London. The health system opened a 184-bed hospital in central London in March, its second facility in the city.

Sanford looks to help countries like Ghana — where it helped create the country’s first electronic health registry — create sustainable, quality medical care, Garcia said.

But it may be more expensive to finance international operations because of the pandemic, the researchers said.

The cost of international marketing and the complexity of managing foreign customers has increased dramatically amid COVID-19, Rush Health researchers and medical tourism consultants wrote in a 2021 peer-reviewed paper. The pandemic has been a tipping point for providers who develop more sophisticated telehealth strategies to reach patients abroad, the researchers noted.

While telehealth has expanded rapidly domestically during the pandemic, international restrictions may limit its reach.

“In response to these challenges, academic medical centers will reexamine their foreign market strategies, and those with significant investments in offshore locations will hedge their bets by reducing their exposure to those foreign operations and locations. “, says the study.

Neither Cleveland Clinic nor Sanford plan to slow their international expansion plans or reach out to attract medical tourists, executives said.

“We are anticipating an increase over the next five years in international patient volumes,” Rimmerman said. “Our goals from an international perspective are strong.”

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