Offshore Health Solutions

General Franchise Description

Offshore Health Solutions is a global franchise of medical and research facilities located aboard oceangoing vessels and seasteads. Medical procedures are conducted in international waters to avoid unnecessary red tape, and to allow increased availability of health alternatives at a lower cost in an environment of practical consumer-based accountability and service.

Mission Statement

To facilitate advanced and state-of-the-art health and medical services with the highest standards of quality at a significantly lower cost by capitalizing on offshore provision, international competition, and market-based regulation.

Franchise Goals

1) Providing access to alternative care that would otherwise be highly regulated - with an initial focus on less controversial treatments and procedures. Allow the marketplace to prove itself as the best regulator.

2) Lowering the cost and increasing the quality of provision of medical services by allowing greater competition among providers. Medical tourism is driven mostly by the lower cost of foreign medical care for comparable treatment.

3) Granting insurance companies a greater role in the evolution of offshore medical practices and in directing the finance of medicine. Any factor determined to be quantitative by actuarial science is the natural basis for pricing - including lifestyle, genetics, preexisting medical conditions, demand, &c.

Franchise Objectives:

1) Complete a pilot unit on an existing vessel and cruise line within the year.

2) Initiate the franchise with three vessels (one franchise unit per vessel), one Master Franchisee, and one Area Representative within a year after the pilot.

3) Allow Master Franchisees to expand the number and scope of sub-franchisees with a maximum of two each until three Master Franchisees, and then allow additional Master Franchisees. Each will be limited to forty nine percent of the number of patients served and to twenty one percent of the total cost of each type of procedure conducted within the franchise (including follow-up, recuperation, and other settlement) after the sub-franchisee is added.

4) Support franchisees in the purchase and operation of vessels or in establishing or expanding to stationary or floating SeaSteads.

Business Philosophy:

1) Offshore Health Solutions will offer the ultimate price-quality guarantee. The combined costs for any medical procedure and the entire trip will be less than one half that of a comparable unsubsidized procedure done in the United States, and meet or exceed quantifiable quality measures for a comparable procedure.

2) Offshore Health Solutions will provide an enjoyable and seamless experience with advanced logistics, a state-of-the-art international medical informatics infrastructure, and continued follow-up.

3) Offshore Health Solutions will achieve the highest safety standards possible by accepting full financial accountability for unanticipated outcomes.

4) Offshore Health Solutions will provide an environment for cutting edge and alternative medical care at a significantly reduced cost by capitalizing on the global marketplace for the provision of medical services.

5) Offshore Health Solutions will encourage a close relationship between medical professionals and insurers in order to meet the highest standard of quality possible at competitive rates.

6) Offshore Health Solutions will provide access to certification tools and rating services in order to ensure the highest level of competence among medics.

Franchise Overview

Products and Services

1) Offshore Health Solutions will begin offering medical procedures with the widest disparity of costs such as the following:

• Heart valve replacement
• Heart bypass
• Hip and knee replacement
• Spinal fusion
• Angioplasty

The offerings will then expand into additional procedures that uphold its price/value guarantee.

2) Offshore Health Solutions will offer a variety of health solutions and coordinate on-board activities and infrastructure with the various cruise lines:

• Health food store with OHS approved products
• On-board on-call pharmacist/nutritionist
• Coordinated health and diet maintenance
• Coordinated gym and physical activities/therapies

Operational Framework

Executive Office

Training, operational support, overall vision and structure of franchise and all of its components.

CEO answerable to Las Portadas (actions and decisions may be vetoed by 40% of BOI, HLR, GCI, or CUALP)

Financial Office

Financial analyses, payment structures, marketing, pricing

Medical Informatics Office

Availability of medical records, procedures, outsourcing resources

Actuary

Advises underwriters regarding mathematical feasibility of coverages

Area Representation

Government and legal interface issues

Unit Franchisee

Limited to one vessel or stead

The Market

American consumers are the prime growth force behind medical tourism. As many as 750,000 sought offshore medical care in 2007, spending an estimated $2 B.

Current Healthcare System

US health care spending continues to rise at the fastest rate in history.

In 2007, total national health expenditures increased 6.9 percent — two times the rate of inflation. Total spending was $2.3 T in 2007, or $7600 per person. Total health care spending represented 16 percent of the gross domestic product (GDP).

U.S. health care spending is expected to increase at similar levels for the next decade reaching $4.2 T in 2016, or 20 percent of GDP.

In 2007, employer health insurance premiums increased 6.1 percent - two times the rate of inflation. The annual premium for an employer health plan covering a family of four averaged nearly $12,100. The annual premium for single coverage averaged over $4,400.

Experts agree that our health care system is riddled with inefficiencies, excessive administrative expenses, inflated prices, poor management, and inappropriate care, waste and fraud. These problems significantly increase the cost of medical care and health insurance for employers and workers and affect the security of families.

Business Drivers

The number of Americans heading abroad for medical procedures is surging as domestic medical costs reach unaffordable levels. Mexico has long attracted American travelers looking for cutrate cosmetic surgery or dental work, and countries like India, Malaysia, Thailand and the Philippines continue to lure medical tourists as well. Last year, India attracted 150,000 medical tourists from the United States, Britain, Africa and elsewhere in South Asia, largely by offering an enticing trio of advantages: highly trained English-speaking doctors, quick appointments and bargain-basement prices.

The benefits of medical tourism are compelling.

• Potential Savings - The driving force behind the medical tourism market is the potential

cost savings. For those without insurance or those needing operations that insurance won't cover, medical tourism can be an affordable alternative to the skyrocketing costs of health care. Costs for major surgeries in the United States can run into the hundreds of thousands of dollars while the same surgery in a country like India or Thailand can be as little as a tenth of that.

• Shorter Waits - Even people who live in countries with public health care coverage (UK

and Canada) often choose to take their treatment abroad as overburdened hospitals and doctors can have long waiting periods for surgeries on conditions that are not lifethreatening.

• Quality - Many of the countries where medical tourism has become popular have made

significant investments in the industry to ensure that patients are happy and healthy. Many doctors have been trained abroad, and some are leaders in their fields.

• Relaxing Recovery - Traveling for medical treatment offers the added benefit of a

relaxing vacation while in recovery.

• Growing Insurance Coverage - An increasing number of insurance providers are

offering coverage for foreign medical alternatives provided that it isn't an elective procedure.

• Bring Friends and Family - Because of the significant cost savings on treatment abroad,

it is often possible to bring others along and still spend less.

• World Class Facilities and Equipment - With medical tourism growing rapidly,

hospitals are making big investments in equipment and technology to help them draw more patients.

• Package Deals – Several companies specialize in providing patients with not only their

treatment, but vacations afterwards, travel to and from the airport and all of the accommodations needed.

• Surgical Options - While the most popular options with medical tourists are cosmetic

and dental surgeries, there is a growing market for a wide variety of procedures including heart surgery and orthopedic hip and knee replacements.

• Luxury Accommodations - Many hospitals that cater to medical tourists are corporately

owned and therefore are in staunch competition with other hospitals to draw you in to their facilities.

• Service - Patients can usually expect a high level of personal care and attention from

hospitals and clinics that are popular with medical tourists.

• Travel is Affordable - While fuel costs have risen in the past few years, air travel is still

an affordable and relatively convenient way to travel.

Facts and Figures

In the United States, an estimated 49 MM people are without health insurance and 120 MM are without dental coverage - numbers that are both expected to grow. Countries like Britain and Canada have public health care systems plagued by long waiting lists for most major surgeries. This stimulates the need for foreign health care alternatives.

In addition, the high cost of the U.S. health care system has put many US businesses at a competitive disadvantage with foreign firms. The US automotive industry is the poster child for the dilemma posed by high employee medical costs: GM, Ford, and Chrysler's medical costs amount to $1,000 to $1,500 per sold car, which greatly exceeds the medical costs for Japanese, Korean, and European competitors. Simply put, countries such as India, Thailand, Mexico, and Costa Rica can provide equivalent healthcare treatment at much lower prices than in the United States.

The cost of surgery in India, Thailand or South Africa can be one-tenth of what it is in the United States or Western Europe, and sometimes even less. A heart-valve replacement that would cost $200,000 or more in the U.S., for example, can be had for $10,000 in India--and that includes round-trip airfare and a brief vacation package. Similarly, a metal-free dental bridge worth $5,500 in the U.S. costs $500 in India, a knee replacement in Thailand with six days of physical therapy costs about one-fourth of what it would in the States, and Lasik eye surgery worth $3,700 in the U.S. is available in many other countries for only $730. Cosmetic surgery savings are even greater: A full facelift that would cost $20,000 in the U.S. runs about $1,250 in South Africa.

Faced with surging global popularity, numerous countries are creating options for this lucrative market including: Argentina, Costa Rica, Cuba, Jamaica, South Africa, Jordan, Malaysia, Hungary, Latvia and Estonia.

Future Outlook

Employers make a push for 'medical tourism'

U.S. health care costs have gotten so outrageous that some small employers save money by flying workers to foreign countries for inexpensive medical procedures.

Until recently, medical tourists were mostly individuals seeking low-priced cosmetic and elective surgery not covered by insurance. But more than one million Americans will travel overseas for procedures this year, and a rising proportion are getting insurers or employers to pay part of the cost.

While global medical tourism has yet to make major inroads with U.S. employers, some small employers and benefit providers such as BlueShield and BlueCross are starting to take the idea seriously. Experts predict that the medical tourism industry will grow to $40 B by 2010.

Medical tourism will grow regardless of possible U.S. universal health plan.

While president Obama is calling for a universal healthcare system, experts predict the adoption of a universal health plan will not affect medical tourism. The industry will continue to grow for the same reasons it is growing in countries like UK and Canada.

The demand simply outstrips the supply. Medical tourists will continue to use foreign alternatives to avoid long waiting periods, and save on costly elective procedures that are not covered by any healthcare plan.

Insurance companies are beginning to embrace ‘Medical Tourism.’

According to David Boucher, an assistant vice-president of health-care services at Blue Cross & Blue Shield of South Carolina, Blue Cross and other insurers would like to see more policyholders traveling abroad for medical care. “As healthcare costs continue to rise in the U.S., medical travel is going to be part of the solution.”

Like manufacturing facilities and call centers, health care is moving offshore. According to Jonathan Edelheit, president of the Medical Tourism Assn., “All of the largest U.S. insurers are starting to educate themselves or are putting [offshore] programs in place.”

Insurance companies could waive all deductibles and co-pays, offer to cover travel costs for the patient and family members, even throw in a cash incentive, and still save tens of thousands of dollars.

Blue Cross took the lead in medical “offshoring” when its Companion Global Healthcare subsidiary formed its first partnership, with Bumrungrad Hospital (Bangkok, Thailand), in February 2008. Since then, Companion Global Healthcare has signed similar pacts with the Parkway Group Healthcare, owner of three hospitals in Singapore, and with hospitals in Turkey, Ireland, and Costa Rica. Three members of India's Apollo Hospitals Group are also joining the network. And another large Indian chain, Wockhardt Hospitals, is working with U.S. insurers as well.

Charles Cutler of Aetna notes that the savings for his firm are not as great as they may be for some others, since it gets volume discounts from American hospitals thanks to its size. Travel abroad for Aetna’s clients makes sense only for procedures costing $20,000 or more, which might include heart and orthopedic surgeries. He remains bullish, observing that quality at the best foreign facilities can be much better than at the average American hospital, thanks to greater transparency and better information technology. He thinks this is inspired by the Asian hospitals’ need to market to a skeptical foreign audience.

The Booming Cruise Ship Industry

The Cruise Industry is the fastest growing sector of the Travel Industry. Its economic benefit to the US economy was estimated at $35.7 B in 2006. An estimated 12.5 MM people took a cruise in 2007; up nearly half a million from 2006.

The number of new ships continues to grow, reflecting optimism about the future. Nearly 40 ships were built in the 1980s; nearly 80 in the 1990s, and roughly 100 new ships will have been introduced since 2000. Additionally, there are an increasing number of small niche operations, catering to more specific markets. Overall, the market is by no means exhausted; only about 17 percent of US adults have taken a cruise.

The average cruiser is now 49 years of age, down from the stereotype "older" market of the past. Average household income of cruisers is $104,000. Florida, California, and Texas are the big three states for cruise patrons.

Cruise Vacation as an Ideal Solution for Recuperation

Increasingly, medical tourism operators are emphasizing the vacation aspect of the medical tourism excursion to lure patients to their facilities. By way of example, some destinations in Africa offer safaris, a few in Thailand offer jungle excursions, and several in India provide daytrips to the Taj Mahal.

In recent years the cruise experience has become increasingly luxurious. Major cruise lines now offer larger rooms, bigger beds, and marble lined bathrooms. In addition, many staterooms now include butler services.

The newest addition in cruise line luxury is the spa-focused retreat. Carnival Cruises is introducing the line's first spa staterooms, with private access to a luxurious 6,400-square-meter spa. Cruises have become the ideal recuperation experience; with therapeutic spas, world-class entertainment, and 5-star dining, surrounded by the calm of the sea.

Cruising is considered to be one of the most comfortable holiday options. Compared with other types of vacations, cruising has the highest percentage of extremely satisfied customers (45%), outpacing all-inclusive resorts (42%) and visiting friends and relatives (40%). 82% of cruisers gave the industry high marks and ratings fell in the ‘very’ satisfied and ‘extremely’ satisfied categories. Moreover, the comfort level associated with cruising is also high as compared with other vacation alternatives. About 57% of respondents in a survey stated that cruises are superior to other types of vacations in terms of overall pampering, and about 52% of people rated it as the most luxurious vacation option.

Competition

Basis of Competition

As noted above, numerous countries are entering into the lucrative medical tourism industry. Each country seems to specialize in a given area of medicine, with one or more reputable establishments catering to medical tourists. However, despite the size of the competitive landscape, the number of prominent facilities remains small.

Competitive Landscape - Hospitals

Direct Competitors

• Anadolu Medical Center - Istanbul, Turkey
• Blackrock Clinic - Dublin, Ireland
• Bumrungrad International Medical Center - Bangkok, Thailand
• Hospital Clínica Bíblica - San José, Costa Rica
• Parkway Group Healthcare - Singapore

Indirect Competitors

• Apollo Hospitals Group – Major player throughout Asia
• Wockhardt Hospitals – Major player in India

Competitive Landscape - Cruise Lines (Indirect)

The operators listed below are the Who’s Who of the cruise line business but since none in the Medical Tourism space, these are, at most, indirect competitors.

Royal Caribbean – Also operates:

• Celebrity Cruises
• Pullmantur Cruises
• Azamara Cruises
• Partial ownership of Island Cruises

Carnival Cruise Line – Affiliates include:

• Holland America Line
• Princess Cruises
• Cunard Line
• Costa Cruises
• Yachts of Seabourn

Star Cruises – 50% stake in:

• Norwegian Cruise Line
• NCL America

Direct Competitor Profiles

While there are countless players in the medical tourism industry, there are several that have distinguished themselves as leaders in the field. These hospitals serve international patients and have received accreditation by the Joint Commission International, demonstrating a commitment to meeting the highest standards of care. These hospitals have also established partnerships with the overseas hospital network of Companion Global Healthcare Inc.

Bumrungrad International Medical Center - Bangkok, Thailand

Bumrungrad Hospital Public Company Limited, through its subsidiaries, operates hospitals and health care centers primarily in Thailand. It offers various medical services, which include treatments and procedures, such as cosmetic surgery, reconstructive surgery, skin treatment, and hair transplantation. The company operates various health care centers for allergy, children, dental care, diabetes, diagnostic and therapeutics, dialysis, digestive disease, emergency, eye and eye laser refraction, health screening, heart, orthopedics, plastic surgery, rehabilitation, skin and skin laser, sleep disorders, and women’s health centers. It also operates medical clinics and surgical clinics. In addition, the company invests in other companies, as well as engages in the rental of properties service. Bumrungrad Hospital was founded in 1980 and is based in Bangkok, Thailand.

Bumrungrad Hospital Public Co. Ltd. is preparing to invest THB 3.3 billion (US$103.14 million) over the next three to five years to expand and renovate the country's largest private hospital complex. The goal is to provide a balance of services between inpatients and outpatients, as the company is also expanding outpatient service capacity from 3,500 to 6,000 patients per day over the next five years.

======Parkway Group Healthcare Pte Ltd. – The United Kingdom, Singapore, Malaysia, India and Brunei======

Parkway Group Healthcare Pte Ltd. operates a network of private hospitals across South East Asia and the United Kingdom. The Company provides laboratory services, health plan services and primary healthcare such as screening, maternity, diagnostics and various surgery operations. The group has established a website to provide users with information, online appointment booking and a direct link to the group’s hospitals network. The company is based in Singapore, Singapore.

Parkway's other healthcare networks include Parkway Shenton Medical Group, one of Singapore's biggest providers of general practice services; Medi-Rad Associates, a leading radiology services provider; and Parkway Laboratory Services, a major provider of laboratory services.

Parkway Group Healthcare Pte Ltd is looking to invest in Khubchandani Hospitals and pick up its 50% stake for INR 1.55 billion (≈US$37 MM). Koncentric Investments will hold the remaining 50% stake in the firm which plans to set up chain of hospitals and healthcare facilities in India.

Anadolu Medical Center - Istanbul, Turkey

Anadolu Medical Center is a not-for-profit multi-specialty medical service provider based in Istanbul, Turkey. The hospital has been operating since 2005. It offers treatments in oncology, cardiology, ophthalmology, endocrinology, gastroenterology, rheumatology, nephrology, dermatology, and neurology among others. Patients can expect savings of up to 50%-80% from typical US prices.

AMC is a JCI-accredited hospital affiliated with Johns Hopkins Medicine. AMC serves patients from over 40 countries. 35% of its physicians are board certified in the United States.

With 209 beds and nearly 100 physicians, Anadolu has been recognized as a Designated Center of Integrated Oncology and Palliative Care by the European Society for Medical Oncology.

Anadolu Medical Center has joined with Healthbase Online Inc., a Boston-based medical tourism facilitator.

Blackrock Clinic - Dublin, Ireland

Blackrock Clinic came into operation in 1984 with the opening of an out patient complex. The hospital has both private rooms and a small number of semi-private rooms. It also includes a Coronary Care Unit and Intensive Care Unit, a Day Care Facility and an Oncology Day Ward. The services of the hospital involve the treatment and care of the acute medical, surgical and dental patient.

Blackrock Clinic Limited reported earnings results for the year 2006. For the year, the company reported profit rose 34% to €10.3 million on turnover of €77.4 million. The company attributes the rise in turnover to significant investment in new and existing services. The company paid dividends of €4.2 million, up from €3.64 million in 2006.

Blackrock Clinic Limited in Dublin revealed plans for a EUR 100 million expansion that will see a 42% increase in the number of beds. The private hospital's expansion will include a threestorey extension to the existing facility and a multi-storey car park. When completed, the total 18 number of beds at the clinic will be 160 and all patients will be accommodated in single rooms. Under the plans, there will also be two new operating theatres and a daycare floor. The expansion is expected to create 100 clinical and administration jobs in the hospital, bringing total employment to 650 people.

Hospital Clínica Bíblica - San José, Costa Rica

Hospital Clínica Bíblica is the largest private hospital in Costa Rica. Founded in 1929, is leading private medical center in the Central American region; offering world-class medical services. Around 50% of the staff has undergone training in the US. The hospital boasts a 50 million dollar infrastructure, including a new 35 million dollar hospital building. Its offering covers orthopedic and bariatric surgeries, to reparative and restorative treatments like LASIK, cosmetic/plastic and dental surgeries.

HCB is in the process of obtaining the Joint Commission International Accreditation (JCI). The hospital is affiliated with the Ochsner Medical Institute & Tulane University School of Medicine in the United States.

Hospital Clínica Bíblica has partnered with Healthbase Online Inc.

Strategy

Pricing

(lease valuation procedure)

Management and Organization

Professional and Advisory Support

• Management advisory board
• Legal counsel
• Financial strategist
• Insurance agencies
• Banker
• Consultants
• Mentors and key advisors

Financial Model

Fees

• Franchise fee (minimal: cost of materials and services provided times two)
• Royalty (regressive payment structure)
• A la carte charges (components available for purchase)
• Fee structure per unit
• Multi-unit fee structure( for master franchisee?)
• Advertising (appropriate venues and costs per venue)
• Etc.

Description of the financial risks and advantages of the expansion models selected

Short term

• Orthoscopic -> Heart valve replacement, &c
• On-board Health store/ Pharmacy
• Lease -> purchase of cabins/zone of ship -> ships

Long term

• Charter -> purchase of vessel -> vessels
• Acquisition of cruise line -> lines
• Participation in construction of fixed ClubStead and/or MedStead on SeaLand
• Biotech research facility

See also

• Las Portadas
• ClubStead Master Lease
• Restitution Transfer and Recoupment
• Constitution of the Autonomous Freezone of Aquia

Guiding principles

• Instead of Politics (Civilization 101) by John Frederic Kosanke