Enhancing Urgent Care Profits with Travel Medicine

Urgent message: Travel medicine is a service addition that enables urgent care operators to attract more patients and increase revenue from existing patients while leveraging existing infrastructure and personnel.

When an urgent care center’s patient revenues exceed operating expenses, the operation is said to have achieved break-even profitability—at which point each incremental patient visit contributes directly to the bottom line. Nevertheless, in the face of rising fixed costs and falling payer reimbursements, many centers still struggle to grow profits year after year. Thus, urgent care operators often look to ancillary services to boost profitability and add additional revenue streams.

Ancillary services have numerous advantages. Many can leverage pre-existing clinic infrastructure, patients are treated to convenient “one-stop shopping” via receiving multiple services under one roof, the billing model is typically cash-only, and they help raise public awareness of the center by attracting new patients. There are many ancillary routes an urgent care operator can explore, with the potentially profitable service of travel medicine among them.

Travel Medicine Basics
The Cleveland Clinic defines the objectives of travel medicine as follows:

• Counsel patients about how to avoid risky behavior and exposure to infectious agents or disease vectors (pretravel counseling).
• Immunize against illness when it is difficult to limit exposure.
• Use preventive or symptom-triggered medications when immunization vaccines are not available.

Travel medicine remains a wide-open market. According to the Federal Office of Travel & Tourism Industries, U.S. citizens have made close to 300 million visits to international destinations in the past decade. However, many of these destinations lack basics like clean water systems and disease control programs that most Americans take for granted. Disease vaccinations and travel safety education are, therefore, very much in demand for international travelers, and can provide a valuable revenue stream to a clinic willing to offer travel medicine services.

Getting Started in Travel Medicine
Provider Certifications in Travel Medicine
Clinicians who offer travel medicine do not require any unique “certification,” as the field isn’t a specifically recognized medical specialty. Travelers who want to maximize the likelihood that they’re receiving quality, travel-related care, however, will likely verify that their chosen travel medicine provider has an active membership with at least one of the leading travel medicine organizations, such as the International Society of Travel Medicine (ISTM; http://www.istm.org/) and the American Society of Tropical Medicine & Hygiene (ASTM&H; http://www.astmh.org/)

Membership in a travel medicine organization offers benefits such as access to a professional network of peers, listings in online global travel clinic directories, official certification, member discounts on travel medicine-related products and supplies, and recognition as a leader in travel medicine. Even with a travel medicine organization membership, though, the field continues to evolve and grow amid an ever-changing global landscape. As such, providers typically need to perform no less than 10 pretravel consultations per week to maintain the expertise necessary to provide competent advice and care.

The Basics of Travel Medicine
Travel medicine consists of two primary services: travel medicine consultations, and travel vaccinations.

Travel medicine consultation: Many travelers are unaware of, or take for granted, risks associated with travel. When they learn about infectious diseases and unsafe water, however, they’re generally more than happy to pay for a consultation. The basics of a consultation are as follows:

• Review the patient’s travel itinerary and planned activities.
  • Consult travel health software to determine international health risks at patient’s destination. TRAVAX (www.travax.nhs.uk), an interactive, membership-based website that provides real-time travel health information for healthcare professionals, is the most commonly used software. The website of the Centers for Disease Control and Prevention (CDC; www.cdc.gov/travel) also has up-to-date, global travel health information.
• Conduct a medical history and physical exam to assure patient can participate safely.
• Provide a travel kit for the patient to take on the trip:
  • Generally, contains basic first aid items; prophylactic meds for malaria, traveler’s diarrhea, motion sickness; antibiotics, etc.
  • Attractively packaged and sold for a price premium.
• Conduct a post-trip follow-up evaluation to assure patient is medically clear to resume regular life activities.

Travel vaccinations: Ensure that the patient has the required/preventive vaccinations for each planned destination.

Getting Set Up as a Travel Medicine Clinic
Following are the medical record components, policies and procedures, and equipment and supplies needed to provide travel medicine services:
Medical Record Components

• Standard travel clinic form (for consistent charts). Travelers should complete the form, which should be available on your website, in advance and emailed to you when the appointment is scheduled. Clinics should also have forms available when the patient checks in or in the waiting room in case the traveler forgot to bring them.
• Traveler Demographics
  • Name, date of birth, address, phone numbers, email address
  • Referring physician name, address, telephone/fax numbers
  • Referring business name and address (if occupational medicine)
  • Dates of departure and return
  • Destination—countries and areas within countries (ie, urban vs rural)
  • Nature of travel—business, sightseeing, visiting friends/relatives, study/teaching, missionary service
  • Medical history
    • Pregnancy, immunosuppressing conditions, HIV risk factors
    • Medications
    • Medication or food allergies (particularly to eggs for the vaccines)
    • History of hepatitis or jaundice
  • Travel history/travel-related illnesses
  • Country of birth and duration of residence
  • Unusual illnesses
  • Immunization history
  • Advice given
  • Medications given
  • Immunization form for vaccines administered
    • Required information: Vaccination type, dose, date of administration, manufacturer and lot number, site of administration, name and title of administrator
  • Comment section (eg, patient refusal to receive certain recommended vaccinations or prophylactic measures)
  • Signature line

Policies and Procedures

• Informed consent for vaccines (patients need to read and hear clinician recite information about the potential benefits and side effects of each vaccine)
• S. Public Health Service written Vaccine Information Statements. For vaccines not covered by these statements, the manufacturer should have a written information sheet that can be used. Otherwise, the clinic should write its own information statements. Additional information can be found at the following CDC link: http://www.cdc.gov/vaccines/hcp/vis/index.html

Equipment and Supplies Needed

• Facilities
  • Waiting area displaying travel magazines, health bulletins, and educational videos
  • Consultation and vaccine administration rooms
  • Computer in each consultation room for accessing the travel medicine practice database
  • Fax machine for obtaining vaccine records or insurance referrals from traveler’s PCP
  • Refrigerator and freezer for vaccine storage. Keys to vaccine storage:
    • Vaccine storage should be sole use
    • Refrigerator/freezer should be plugged into emergency power source to prevent accidental spoilage, and/or connected to an alarm for alerts should temperatures deviate from standard
    • Mandatory monitoring and recording of temperature twice daily, especially for yellow fever vaccine
    • Temperature ranges
      • Refrigeration 35⁰-46⁰ F (optimal: 40⁰)
      • Frozen storage (yellow fever, Varicella) ≤5⁰ (optimal: 0⁰)
    • Vaccines should never be stored in the refrigerator door, due to potential exposure to warmer temperatures
  • Vaccine logs to assure supplies are always sufficient to meet demand
  • Yellow fever vaccine – Regulated by state departments of health, requirement of designated medical director and reporting of adverse events; validation stamp to be recorded on the International Certificate of Vaccination.
  • Supplies
    • Latex gloves, syringes of multiple sizes, needles of different lengths and gauge, bandages, alcohol pads, cotton gauze, lidocaine/prilocaine cream, sharps receptacle, adrenaline, and antihistamines

Travel Medicine Process
The clinical process of a travel medicine service could be best illustrated as follows:
Call for appointment à Conduct pretravel physical à Issue travel kit à Administer vaccinations
à Conduct post-travel physical
Call for Appointment
Traveler arranges appointment with clinic. This is when the travel form should be completed, prior to the in-person visit, allowing the physician to check immunizations and acquire vaccine supplies. This is also the time when the clinic can begin providing an excellent pre-appointment experience:

• Create a personal rapport with the patient and set expectations for the visit during the call
  • Put knowledgeable, enthusiastic, and informative staff on the phone
  • Have a precrafted script for dealing with prospective travel medicine patients
  • Hand off call to travel medicine nurse or administrator, or promise a callback if front desk staff/receptionists are unfamiliar with the program
    • Be sure to call back within an hour
  • Explain how long the visit will take, what will be discussed at the appointment, and benefits of the consultation
    • Questions to ask of patient:
      • Are you a frequent traveler?
      • Do you have an immunization record?
      • What insurance do you have? (Note: Insurance rarely covers travel medicine services administered in urgent care centers.)
    • Information to tell the patient:
      • How long the appointment will last
      • What will happen at the appointment
      • What to bring to the appointment
      • What the appointment will cost
      • What immunizations will cost
      • Insurance billing policy/payment terms
    • Refer patient to website/web resources

The physician should schedule 1 hour for the actual consultation. Patient should bring a driver’s license/passport/ID, immunization records, medical history, travel itinerary, and payment. Depending on the nature of the consult, it could either be a nurse simply administering the needed vaccines per the CDC website, or a physician conducting an in-depth examination including:

• Patient health history
• Review of trip itinerary
• Review of safety information for each destination
• Cultural topics that could potentially affect patient health (ie, food, weather)
• Administration of some, or all, recommended vaccinations during the initial visit

Pretravel Physical
The pretravel physical is much like a standard physical, and may include the following testing, as required by some countries prior to obtaining an entry visa:

• Serology for immunity to hepatitis A
• Serology for immunity to hepatitis B
• Serology for immunity to measles
• HIV testing

Table 1. Criteria for Clinics Providing Yellow Fever Vaccinations
Yellow fever is a viral infection that occurs in Africa and South America. About 99% of people develop immunity within 1 month of receiving the vaccination. The vaccination, however, is not without risks (including severe allergic reactions, neurological problems and organ failure) and is thus regulated more strictly than other vaccinations by state health departments. Most states require certification and a stamp to administer yellow fever vaccine.Follows are the general guidelines for providing yellow fever vaccination as part of an international travel clinic:

• Provide a comprehensive personal travel consultation and risk assessment to patients before and after international travel.
• All clinic staff, including physicians, physician assistants, nurse practitioners, registered nurses, licensed practical nurses, medical assistants, etc. who are prescribing or administering yellow fever vaccination must complete the Yellow Fever Vaccine Course at the Centers for Disease Control and Prevention website (https://wwwnc.cdc.gov/travel/page/yellow-fever-vaccine-course). State health departments often require a continuing education certificate for each staff member seeking authorization to provide the vaccine.
• Provide travel vaccinations to include hepatitis A, hepatitis B, polio, measles, mumps, rubella, tetanus, diphtheria, pertussis, pneumococcal, meningococcal meningitis, rabies, rotavirus, human papillomavirus, varicella, zoster, Japanese encephalitis, typhoid, and yellow fever. The facility must also provide prophylaxis for malaria.
• Ensure that a physician will be immediately available to handle any severe adverse reactions.
• Ensure that a protocol is in place for anaphylaxis treatment, that staff receive training, and that the protocol and training are reviewed annually. In addition, the clinic must demonstrate appropriate and adequate knowledge of basic life support and CPR.
• Have an agreement with a laboratory to test and diagnose parasite infections.
• Demonstrate adequate resources for acquiring up-to-date information on travel recommendations, restrictions, and requirements, eg, the CDC’s “Yellow Book” and travel website; travel warnings of the U.S. State Department; the World Health Organization’s International Travel and Health Vaccinations Requirements and Health Advice; and TRAVAX.
• Demonstrate knowledge and understanding of the procedure for reporting vaccine adverse reactions to the federal Vaccine Adverse Event Reporting System (VAERS) and to the state department of health.
• Ensure that the clinic obtains one official yellow fever vaccination stamp specifically registered to it by the state department of health, using the state licensure number of a provider currently practicing at the facility. This number will be on file at the state health department and the CDC. If the provider whose license number is on the stamp leaves the clinic, ensure that a new stamp is obtained and the old one is returned to the state health department. Report any lost or stolen stamp to the state health department immediately.
• Only administer yellow fever vaccine at the address indicated in the certification letter and never redistribute the vaccine to other sites.
• Participate in periodic workshops and conferences related to travel medicine.

(Adapted from: Minnesota Department of Health, Criteria for Clinics Providing Yellow Fever Vaccinations. http://www.health.state.mn.us/divs/idepc/immunize/travel/yfccriteria.pdfAccessed July 6, 2016.)

Issue Travel Kit
Suggested contents of a basic travel health kit include the following:

• Patient’s usual prescription medications (including extras)
• Analgesic (aspirin or acetaminophen or nonsteroidal anti-inflammatory)
• Throat lozenges
• Decongestant
• Antihistamine
• Cough suppressant/expectorant
• Loperamide
• Antibacterial wipes or towelettes
• Antibiotic for diarrhea
• Bismuth subsalicylate
• Sunscreen
• Antifungal cream
• Steroid cream
• Antimalarial medication
• Insect repellant
• Bandages and adhesive
• Water purification tablets
• Oral rehydration salts
• Tweezers/scissors
• Antacid
• Digital thermometer

The travel medical kit should be well organized in a protective and convenient carrying case or pouch. Extremes of weather, terrain, and activity should be factored into its contents. Especially for travel to developing countries, some experts suggest also carrying needles, syringes, and intravenous catheters, as these instruments, in some countries, are often reused under nonsterile conditions.

Administer Vaccines
Travel Immunizations Include:

• Hepatitis A
• Hepatitis B
• Typhoid
• DTaP (diphtheria, whooping cough, tetanus)
• Tetanus
• Yellow fever
• MMR (measles, mumps, rubella)
• Meningococcal
• Rabies
• Antimalarial (prescription)
• Antibiotics (prescription)

Should the patient not have their immunization record, the physician can still move forward with the consult under the assumption that those vaccinations have not been administered.

Post-travel Physical
Post-trip follow-up is good marketing, and necessary for medical surveillance. Hence, consultations should be managed by a physician, and all travel medicine specialists should be trained to recognize key symptoms in the returning traveler; they can be referred to the appropriate care provider as needed.

Fees and Revenues
Travel medicine industry anecdote suggests that travelers will pay up to $1,200 for travel vaccines and consultations when necessary. Scott Summers, director of marketing for regional chains for Cardinal Health, goes as far as to say that the total margin opportunity in travel medicine is around 30%. Numbers like these clearly show travel medicine to be a potentially lucrative ancillary service, with the standard fees bearing this out.

Still, prices do vary significantly by provider. Prices for a nurse consultation can range anywhere from $35 to $65, while a physician consultation with a nurse administering the vaccinations can range from $75 to $150. Additionally, providers who are able to effectively articulate the value of a consultation to a patient gain a competitive advantage in regards to pricing. Being aware of lower-cost travel vaccine options such as the local health department, or the pharmacy/retail clinic, is also important, both when setting and justifying prices to patients. Consumers are likely to shop around for travel medicine services, and will make a decision based on either price or confidence in the chosen provider’s expertise/professionalism.

Building Rapport During the Pre-appointment ExperienceAlthough shopping around for medical service providers is not customary in the United States, the discretionary nature of international travel means consumers are likely to have questions. It’s therefore essential that your front-line staff be enthusiastic and prepared to answer pre-visit consumer inquiries regarding:

• How long to block for an appointment
• What would happen at the appointment
• What to do/expect if no immunization record
• What to bring to the appointment
• What immunizations you would require
• What the appointment would cost
• What the immunizations would cost
• Any other possible costs, cost savings, or discounts
• What insurance is accepted
• Payment terms and less expensive options
• Relevant websites/ online resources
• Timeframe of callback, if necessary

The opportunity is to improve the pre-appointment experience with a shorter elapsed time to provide information and set an appointment. Additionally, many providers do a poor job of justifying the cost of a consultation. Explaining the benefits of the consultation not only instills confidence in your capabilities vs your competition, but can also justify a higher appointment price.

Table 2. Travel Medicine Market Conditions

• There are multiple travel health provider choices in most major markets, and potential patients can easily switch among them. Although shopping around for medical providers is not yet customary in the U.S., it is a growing development, and travel health provides an easy opportunity to do so.
• There is free and easy access to information regarding travel health both from the internet (CDC, community health departments, destination websites, etc.) and from phone conversations with providers themselves. Potential users can become very well informed before they spend a dime.
• Customers range from very savvy, frequent travelers to novice first time travelers. Different types of customers require different levels of information and types of customer service. Understanding and designing services for different customer types may present competitive opportunities.
• The basic service package for travel health is fairly consistent among most providers and includes an appointment with a travel health medical specialist followed by the administration of vaccines. Numerous and clear points of competitive distinction may be difficult to create in actual service delivery. However, no providers are currently telling the “travel health story” very well. Opportunity exists to gain competitive advantage by being the best at explaining why the consultation is a critical step in ensuring successful travel.

Travel Medicine Marketing
There are four primary markets that consistently utilize travel health services:

• Evangelical churches, particularly those with a school attached. They generally see heavy utilization for short-term mission trips and frequently travel as large groups.
• Individual travelers (typically senior citizens).
• Immigrants returning to their home country with children born in the United States but not previously immunized for that country.
• Occupational medicine employees, especially airline/transportation employees who need vaccines to work certain routes and/or government leaders and executives in multinational corporations (eg, Ford and GM) who travel abroad frequently.

Marketing tactics for these groups can include:

• Word-of-mouth among travelers, physician referrals, health agencies, or travel agencies
• News releases or interviews to print, radio, or TV media concerning travel medicine care, and/or travel-related topics
• Search engine optimization, pay-per-click advertising (to get top page ratings in Google)
  • Listing in CDC Provider Directory (http://wwwnc.cdc.gov/travel/page/find-clinic/)
• Development of a travel medicine brochure with mailings to: physicians, travel agencies, churches, immigrant/advocacy groups, study abroad offices, and HR offices in global corporations. The marketing brochure should contain the following information:
  • Provider demonstrating knowledge of disease epidemiology and prevention
  • Availability of all vaccines necessary for travel
  • Provision of advice and prevention strategies on uncommon diseases
  • Availability of written resources on disease prevention
  • Additional information for brochure:
    • Information detailing reasons for seeking pretravel care
    • What care will be provided
    • Hours of operation
    • Direction to the facilities
    • Contact numbers
    • Web address
    • Statistics about travel population served by the clinic
    • Pictures of travel destinations
    • Education sessions for physicians and the travelling (lay) public

To reach existing urgent care patients, place travel medicine literature and posters in every exam room. These materials are available from the vaccine manufacturer. This is doubly important during years featuring global events such as the Olympics or the World Cup, wherein global travelers will number in the tens of thousands.
Lastly, after the travel visit, don’t forget to send a letter to the patient’s PCP, detailing which vaccines were administered and what medications prescribed.

Conclusion
In this day and age of increased global travel, travel medicine can be a very profitable ancillary service for urgent care clinics. As a cash-only business, it allows a clinic to develop a substantial revenue stream apart from payer reimbursements and accounts receivables. And with diseases like yellow fever and encephalitis being very real global threats, travelling patients quickly learn what an essential service travel medicine really is.

The key to successfully offering travel medicine services is having a full grasp of the entire clinical process, from the pre-appointment call to the post-travel physical, and properly executing the key details in each step. But regardless of how well a provider can perform a travel health consultation, if the marketing efforts aren’t targeted and aggressive, dollars will be left on the table. Hence, travel health urgent care providers must familiarize themselves with the four primary travel medicine markets, and build comprehensive campaigns that make inroads with key influencers such as evangelical clergy leaders, immigrants, seniors, and career-related travelers.

In sum, travel medicine is a growing business with a sizeable market. For urgent care operators seeking ways to offset the rising costs of doing business, a firm commitment to offering travel medicine service has the potential to reap substantial dividends.