WhiteCoat

Medical Tourism

sas_airplane_1The Chicago Tribune has an AP story about how WellPoint is going to start a pilot program of medical tourism where it will send some non-emergent patients to India for surgeries in order to save money. A knee or hip replacement costs between $65,000 and $80,000 in the U.S., but only costs between $8,000 and $10,0000 in India. As a carrot to get patients interested, insurers will pay for travel, lodging, and the medical procedure for a patient AND will pay travel costs and lodging for a companion.

I think medical tourism is a good idea. I especially like the concept because it cuts out the middle man. Patient pays for care, doctor and hospital provide care. Maybe patient and provider haggle over price. Maybe patient calls around to different hospitals and comparison shops – not unlike reading through the Sunday paper and comparing grocery ads.

It concerns me that now a “middle man” wants to get involved.

I also foresee all kinds of new issues popping up once American insurance companies actively engage in sending people to other countries to have medical procedures performed.
Right now (and this is pure conjecture on my part), unless there is a catastrophic injury I believe that medical tourists effectively give up their right to sue a foreign doctor for malpractice. The patient will have to submit to another country’s malpractice laws. Doubt that the payouts would be anywhere near as big as they are in the US (although the docs might get jail time and 1500 lashes with a whip). To get started, the patient would have to retain an attorney (or attorneys) experienced in both malpractice and in international law.  Think you’ll be able to get some of those on contingency?
Will the insurance company be liable in the US if there is malpractice in another country and the insurance company “brokered the deal”? Maybe you can’t sue the insurer for medical malpractice, but can you sue the insurer for negligent contracting? Will the ERISA shield apply to these types of lawsuits against insurers?
What happens if there are surgical complications? In the US, the price for surgery includes a certain amount of follow-up care (30-90 days?). With foreign surgeries, does the patient stay in India until the complications are resolved? Will the insurance company pay for that care as well? What if there is a complication and family wants to visit? Who picks up the travel and lodging tab?
What if the patient is OK when leaving India, then returns and develops a surgical complication? Surgeons in the US are often hesitant to “become involved in someone else’s screw up” (as I have heard more than one surgeon put it). A “screw up” is already more likely to end up in court. If a US surgeon tries to fix an Indian surgeon’s screw up and the patient doesn’t get better, then the US surgeon may be stuck holding the bag in the event of a lawsuit. If there is a “screw up” do the patient and a companion get shipped back to India to make good on the care?
What happens if, during the trip, the patient has another medical problem?
What happens if the surgery has to be canceled? Free trip for two to India?
Aaaaack! What happens if there is a “never event”? Free care?? Or do those never event thingees only happen in American hospitals?
The most pressing question of all is: Who gets to keep the frequent flyer miles?

The Chief Medical Officer interviewed for the article hinted that insurers are trying to use medical tourism to put the squeeze on doctors to lower their prices for non-emergent procedures like joint replacements. “It may change the game in terms of local contracting conversations,” the CMO said.

Here come those unintended consequences. If doctors get pinched on performing non-emergent surgeries, how are they going to make up for that monetary loss? You got it. Guess what’s going to happen to prices for surgeries that can’t be sent overseas.
That acute cholecystectomy just got more expensive. Don’t want to pay it? Fine. Get on an airplane with your companion and go register in one of those insurer-approved New Dehli “ERs”. Just hope your gall bladder doesn’t explode somewhere over the Bay of Bengal.
Have a hip fracture? Hope your travel companion is someone qualified to administer narcotic pain medications because sitting in an economy class seat with a busted hip for 20 hours is going to hurt. Then again, maybe a hand full of Vicodins will be part of the insurance travel package.

These are all issues that can occur regardless of whether the trips are brokered by an insurance company.

The problem occurs when a third party tries to squeeze in the middle of the doctor/patient relationship – making the consumer pay more and making the provider accept less – so that the third party can make a profit. Some aspects of insurer-brokered medical tourism may work. Ultimately I think that issues like those above will become the tail that wags the dog.

I have a bad feeling about this.

UPDATE MARCH 30, 2009
CNN published an article on medical tourism echoing several of the points above.

8 Responses to “Medical Tourism”

  1. Disciple of "Bob" says:

    Help me out, here.

    You say medical tourism is a good idea, and to support that you only offer a couple of thoughts pertaining to how money changes hands.

    Immediately thereafter, you spend very nearly the rest of your post proposing dozens of reasons why “medical tourism” is a TERRIBLE idea.

    It sure seems to me a Medical Tourism safari is just as likely to ultimately end up in an American Emergency Department anyway. And note that it’s called “Emergency Department” and not “Good Idea Department”. I bet there’s a reason for that…

    Maybe I’m suffering from Irony Deficiency. On the other hand, I *did* forget to take my meds this morning. Dang it!

    Disciple! I have missed your comments! Good to have you back.
    I think that when people arrange for their own medical tourism, they go into it knowing that they won’t get the follow up care and won’t have the same legal rights they have in the US. In essence, they are trading those positives for a lower cost. I wouldn’t even try to make the comparison that the treatment is “worse” – I’ve met foreign docs who have more knowledge in their little toe than I have in my whole body.
    I have no problems with the “free marketization” of medicine – in fact, that’s the way that I think the system has to go in order to become viable. Get rid of the middle man. I’m actually working on a post about that. Look at Lasik surgeries and liposuction. Doctor provides service for price, patient agrees on price, surgery gets done. Both parties walk away happy.
    Now comes the “middle man.” You continue to pay insurance companies the same premium, but now they shuttle you to another country to get you the same care – because it costs the insurance companies less money. Patients have no idea how much it costs to provide the service, but keep paying higher and higher premiums to the insurance company. Who benefits? Patients have potential for more problems and have less recourse. Doctors in India will have the rates for surgery “negotiated down” at the threat of insurers taking their business elsewhere. The only ones who win are the insurers.
    Keep the third parties out of it and I’m fine with the idea of medical tourism – as long as the tourists know what they’re in for ahead of time.

  2. Kathy says:

    An interesting and thought provoking post. People have travelled for years to “poorer” countries for IVF for years. Not too long ago many US citizens were crossing the border into Canada to have Lasik eye surgery since it was so much cheaper. So, it has been happening for “elective” procedures. I’m not sure I like the idea of a middleman either. At least if people go to an Eastern European country or South Africa for IVF and it doesn’t work they aren’t blaming a middleman or suing their hometown RE.

    Interesting to see where this goes…..

  3. TheOtherOne says:

    My dad (in his early 70s) had a knee replaced this spring. His recovery was great, medically speaking.

    The experience? Was horrible. For us and for him. The first two weeks after he got out of the hospital were *miserable*. I don’t think he got in the car, other than to go to doctor appointments, for a couple of months. And that was with NO complications. He was just in pain, and the pain scared him.

    I can’t *imagine* how much worse it would have been if we hadn’t been at home. And the thought of a long flight back at some point in those first couple of weeks? Eeeek! Not me. Not my family.

  4. scalpel says:

    “What if the patient is OK when leaving India, then returns and develops a surgical complication?”

    Then they will be our problem in the ER.

    Or your problem in the ED.

    ;)

    We’re going to grapple.

  5. hashmd says:

    Try gastric bypass or lap banding in Mexico. Much cheaper, unless you have a complication. And these patients can and do frequently enough. Then PCP’s like me have to find someone to help fix or manage the complications.

    If the insurance company wants to shop for the cheaper provider, then they should assume the liability. Period. They are getting what they pay for-doctors operating in a lower cost medico-legal environment, and a lower cost economy. But no followup for complications and no patient protection in case of medical injury from that lack of followup.

    If the insurance wants to outsource, they should do it for EVERYTHING. Got the sniffles? Fly to India for your doctor visit. Why should they cherry pick just the elective surgeries and then underpay the urgent or emergent problems here in the states? My malpractice has to be spread across all my work. That is part of the cost of my doing business. The higher charge for the elective stuff helps pay for the underpayment or non-payment by Medicaid and soon Medicare.

  6. NurseBeth says:

    Several of our surgeons were talking about this recently, and all agreed that they would absolutely not see any of these pts for follow up care when they returned to US, certainly and especially if complications developed. Some of it was the liability issue, much of it was a “screw you buddy” attitude at folks thinking it’s all the same, just get the cheapest price.

    Also, where is the wisdom in having someone sit for the very lengthy flight home when they are at most risk for DVT? Joint replacement pts are very high risk for this, despite the preventive therapies we have instituted.

    I’m jus’ sayin’………

  7. arrrr says:

    What’s particularly galling is the way the newspaper didn’t call Wellpoint on their claim that they were going to save big bucks by threatening those greedy doctors with pay cuts due to medical tourism. It’s simply a lie to claim that surgeon fees are a big part of that $80000.

    I would be shocked – shocked! – if the surgeon took home more than 10% of the cost of the operation. Maybe not even 5%. The reason it’s far cheaper in other countries has very little to do with surgeon fees and everything to do with the cost of malpractice, paperwork, employees, OR time, and everything else. In India they don’t have to do multiple pre-operative “correct site” checks, nor do they have to have “timeouts” and “medication reconciliation” for every patient who comes in for same day surgery. But of course the insurance company plays it like the $200 they’ll whittle off the surgeon fee is the real difference.

  8. marcia says:

    Knowing how the insurance industry like to play bait & switch with benefits, it won’t be long before patients are sent to third-world countries with unstable governments for surgery.

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