When Marwan Al-Fagaan's son needed to come to UCLA Medical Center for soft palate surgery in 1998, he applied for visas at the U.S. Embassy in Kuwait in the morning and got them a few hours later.
In January, Al-Fagaan's brother Hussein sought a visa to come to the U.S. for surgery for a brain tumor. Ten days later, the brother was told he would have to provide another photo, sans beard and traditional Arab headdress, and resubmit his application. When he asked embassy officials in Kuwait City if that would guarantee a visa, they said no, he'd still have to pass a background check and interview, and who knew how long that would take? He decided on laser surgery in England or Germany, where visas are much easier to get.
With such heightened scrutiny of foreigners -- especially those from Arab countries -- since the Sept. 11 terrorist attacks, far fewer patients such as Hussein Al-Fagaan are coming stateside, costing U.S. hospitals millions of dollars from their best-paying customers, said health-care consultants and administrators with overseas clientele.
Most of the drop has been in patients from oil-rich Persian Gulf states, the largest group in the nearly $2-billion-a-year international patient industry. The Mayo Clinic's Middle East numbers are down 53% at its flagship hospital in Rochester, Minn. Johns Hopkins is down 30% to 40%. Children's Hospital Boston has seen a drop of 67%, about the same as the University of Texas M.D. Anderson Cancer Center in Houston.
The main reason: Tightened anti-terrorism background checks have extended the time it can take to get a visa from hours to weeks and months. Many also fear that once here, they could face retaliation, be subjected to legal scrutiny, even be jailed.
Some patients have waited and finally became too sick to travel. Others are heading to Europe, where hospitals are aggressively marketing themselves in the Persian Gulf states.
"If you or your spouse or your child or parents had cancer and were unable to get care, how long would you be willing to wait?" asked Stephen Gudgell, head of the Mayo Clinic's international program.
A research paper by Johns Hopkins' international office estimated that before Sept. 11, 70,000 foreign patients were treated annually in the U.S.
While most hospitals say international patients constitute less than 5% of their total annually, they are the most lucrative, sometimes paying more than twice as much as U.S. patients, and often in cash.
Most Americans cover hospital bills with insurance or Medicare, which pay discounted rates. Overseas patients pay a much greater portion of the bill, whether the money comes from their wallets or, as is often the case with those from the Middle East, their governments.
Seldom is there an insurance company to reject sophisticated blood tests or an expensive body scan. And hospitals don't wait weeks or months for visitors from the United Arab Emirates or Saudi Arabia or Mexico to pay. Most must deposit their estimated treatment costs by the time they arrive.
At hospitals with the largest foreign practices, international patients bring in about double the per capita revenue of U.S. patients, sometimes more, medical industry experts said.
At the M.D. Anderson Cancer Center in Houston, for example, 6% of the patients come from overseas, but they contribute 10% to 12% of total revenue, said Wendeline Jongenburger, the hospital's international program director.
Dr. Joe Straus, an international health-care consultant, said that while foreigners made up just 2% of the patients at Partners International, a group of Harvard's teaching hospitals, those cases brought in 20% of its profits.
Prospective foreign patients must apply for a tourist visa, provide documentation that the treatment is not available in their home countries and undergo background checks and interviews.
In the year after Sept. 11, 2001, the overall number of visa applications to the U.S. fell 20%, and the number of visas issued dropped 21%, according to the State Department's Bureau of Consular Affairs.
Representatives of the International Health Forum, a group of hospitals with the largest number of overseas patients, have met with State and Commerce Department officials to find a way to speed up the visa process for medical cases. The effort has been unsuccessful, said Carol Sayles, director of international health services at Children's Hospital Boston.
"I think it's an impact that's going to be felt for a long time," consultant Straus said. "I don't see anywhere in the near future it's going to be changed."
Mayo, the Cleveland Clinic in Ohio and UCLA have long treated presidents, prime ministers and princes who come with an entourage of security, aides and chefs and take up opulent suites. Because several Gulf states pay for their citizens' health care, hospitals sometimes treat commoners traveling outside their villages for the first time.
Patients come for everything from a comprehensive physical exam to an organ transplant, which can cost more than $300,000. Doctors at Johns Hopkins operated on Augusto Perez for prostate cancer in 1991. The retired vice admiral in the Peruvian navy has returned to Hopkins 17 times for checkups.
Even less celebrated foreign patients bring in enough money that hospitals provide them special services. "We have a coordinator assigned to every patient that comes through the door," said Harris Benny, who heads the international program at Johns Hopkins.
"They talk to you before you come here. They arrange appointments for you, arrange transportation and accommodations. They meet you here. They'll be with you through the clinic visit. They'll help you if you want to go to a particular restaurant, if you want to go grocery shopping. They'll be with you until you get on the plane to go home."
Some medical centers, such as Memorial Hermann Hospital in Houston, will send a jet equipped with sophisticated medical equipment to pick up a sick patient.
"We'd tack it onto their bill," said Ed Muraski, who headed the international programs at Hermann and at Mount Sinai Hospital in New York. "Needless to say, it was extraordinarily expensive. For some people, that's not a boundary."
The foreign patient business boomed in the 1990s, according the Hopkins study, as hospitals sought opportunities to replace profits lost to managed care. The number of overseas patients at Hopkins jumped from 400 in 1995 to 7,000 in 2001. Smaller and lesser-known clinics saw the money that could be made and jumped in.
The hospitals are aggressive in marketing themselves internationally. Mayo has an administrative office in Dubai. Partners has a marketing representative who travels to the United Arab Emirates.
Hospital officials talk up their services with medical attaches at embassies. They travel regularly to foreign countries to meet with royal families and government ministers and to connect with doctors and hospitals who could refer patients. They advertise in foreign magazines. In January, U.S. hospitals sent representatives to a four-day health fair in Dubai.
Medical seminars by American doctors at foreign hospitals also are an opportunity to drum up business. "It's sort of marketing through educational conferences," M.D. Anderson's Jongenburger said.
Miami Medical Alliance, a group of eight hospitals, receives money from Miami-Dade County to help its marketing. It flies in South American journalists for a week, putting them up at fancy hotels so they will write about the medical programs.
Even the director of UC Irvine's relatively unknown international program has traveled to Egypt, Kuwait, Qatar, Saudi Arabia, China and Hong Kong.
Now, as Western European countries with less stringent visa regulations are stepping up their outreach to draw Middle Easterners to their hospitals, sometimes even offering cheaper deals, U.S. hospitals increasingly are turning to Asia, South America and the Caribbean in search of patients.
M.D. Anderson looked at cancer care in Asia and saw a lucrative market. It recently signed an agreement to cooperate with a hospital in South Korea.
Dr. Spencer Koerner, medical director of international health and telemedicine at Cedars-Sinai Medical Center in Los Angeles, recently spent two weeks in Mexico studying Spanish.