Passport to Cheaper Health Care?
You can have surgery for less than half the price, but only in countries where you wouldn't drink the water. Is "medical tourism" a brilliant solution — or a too-risky business?
Two years ago, Jeanne Bennett could barely walk. Severely arthritic at 48, she had tried every nonsurgical remedy — prescription medicine, physical therapy, even acupuncture — but nothing helped. Her best option, said doctors at Duke University School of Medicine, was hip resurfacing, a new procedure developed in England that was in clinical trials in the United States. Since resurfacing was not yet FDA-approved, Bennett's insurance wouldn't cover the $48,000 cost. The married mother of two from Raleigh, NC, had that much in savings, "but the money was supposed to be for the kids" college fund and our retirement," she says. "I had to find an alternative."
Bennett approached her doctor about cheaper options abroad, where the surgery was regularly performed. He suggested the United Kingdom, where she would pay half the U.S. price. Around the same time, in April 2005, Bennett saw a 60 Minutes segment on medical tourism that featured Apollo Hospital in Chennai, India. "I asked my doctor what he thought about going there, but he didn't recommend it," says Bennett. "India's a third world country — he didn't trust the quality of care."
While considering England, Bennett also made contact with Vijay Bose, M.D., a doctor at Apollo Hospital who'd been interviewed on the show. He quoted her a price of $5,600 for the operation and her stay at Apollo Chennai, which is one unit of the 38-center Apollo Hospitals Group. He also gave her the names and phone numbers of two patients he'd treated — one American, one Canadian. When she called them, says Bennett, "they could not have spoken more highly of Dr. Bose as a man and as a surgeon." It was enough to convince her to choose India.
That summer, with one child at camp and another ensconced at her mother-in-law's house, Bennett and her husband boarded an 18-hour flight to Chennai. A hospital representative picked them up at the airport, took them to their hotel, and brought Bennett to Apollo the next day. "There was no checking in — I was taken straight to my room," she says. "Then a parade of people came in to introduce themselves: my surgeon, the head of the nursing staff, the international coordinator, a nutritionist, even the director of the hospital." Bennett stayed at Apollo for five days. "I felt totally taken care of."
Afterward, the hospital's international coordinator arranged for her to spend another five days recuperating 45 minutes away at a luxury beach resort on the Bay of Bengal, for about $700. Dr. Bose recommended she stay there 10 days, but Bennett needed to get home. "By the time I left the hospital, I already felt better than I had in years," says Bennett. Today, she walks normally, without pain. "It's like I never had a hip problem. There were no downsides."
Bennett is one American among tens of thousands who've traveled the globe in recent years for surgery at prices exponentially lower than those in the United States. But while many receive good-quality care, and sometimes even the movie-star treatment that Apollo staffers gave Bennett, patients abroad can also run into problems. "The level of standardization we have in the U.S. doesn't exist in most of the world," says Anmol S. Mahal, M.D., president of the California Medical Association. "Currently, there is no good system in place to help guide people through the maze of interpreting what is good medical care abroad."
| Map of Medical Tourism: A Snapshot Some tourism officials now tally the annual number of foreigners (including Americans) who use their health facilities. Caveat: In compiling these statistics, some countries defined medical tourism very broadly, as anything from surgery to a spa massage. | Thailand:1,280,000 Singapore: 410,000 India: 100,000 Brazil: 45,170 Belgium: 42,000 |
U.S. Health Care: Slicko or Sicko?
No one knows exactly how many Americans have traveled overseas for operations. Excluding cosmetic surgery and dental patients and counting just those seeking essential medical procedures, companies in the business of sending patients abroad estimate an annual total of only about 10,000. "It's simply not as big as it's often reported to be, but it's growing every year," says Patrick Marsek, managing director of MedRetreat, a Chicago-based booking agency that sent 200 patients overseas in 2005 and expects to send 650 in 2007. Other booking companies (often called medical concierges) report similar growth: New York–based Medical Tours International (MTI) arranged care for 60 Americans when it opened in 2002; they project at least 900 clients for 2007. California-based Planet Hospital says this year's number will be 1,200, up from 500 in 2006. Seeing this increased interest, some health insurers have begun selling packages to Americans who want to go abroad for health care.
To leave their country, in some cases for the first time, and undergo surgery halfway around the world, people need to be motivated — and the dollar savings of medical tourism (also known as surgical off-shoring) are persuasively large. In the U.S., heart bypass surgery is $113,000 and up for the operation alone; in Thailand, only $11,000. A hysterectomy, about $20,000 here, costs around $3,000 in Malaysia. And a knee replacement that would run around $48,000 here is $8,500 in India.
Price cuts that enormous might appeal to anyone, but for Americans without health insurance (the number is more than 45 million, reports the U.S. Census Bureau), lower costs can mean the difference between life and death. Researchers at the Institute of Medicine found that more than 18,000 U.S. citizens die every year because they don't have insurance. The National Coalition on Health Care (NCHC), a nonprofit group whose mission is to improve America's health system, estimates that there are also 35 to 40 million other Americans who are either underinsured, like Bennett, or have coverage that doesn't address the reality of their medical needs. Even people with good coverage can end up out of luck if health-plan administrators deny claims, alleging that the treatment isn't "medically necessary." That was dramatized this year in Michael Moore's film Sicko, as was the problem of escalating premiums, which have doubled in the last six years. Many employees are now forced to turn down coverage because they can't afford to pay their share. "Our system is not caring for people the way it should," says Scott Rubinstein, M.D., associate clinical professor of orthopedics at the University of Illinois School of Medicine in Chicago, who has provided follow-up care for medical tourists when they've returned home.
The situation is so dire that in 2001, medical costs drove an estimated two million Americans into personal bankruptcy, even though 75 percent had medical insurance at the onset of their illnesses, report researchers at Harvard University.
In 2006, middle-class men and women who become medical tourists to avoid plunging into poverty were dubbed "America's new refugees" by the New England Journal of Medicine. One such person is Howard Staab, an uninsured carpenter who testified last year before the U.S. Senate Special Committee on Aging. In 2004, Staab ventured to India for a mitral valve replacement that would have cost about $200,000 in his hometown of Durham, NC. At New Delhi's Escorts Heart Institute and Research Centre, the price was 96.6 percent less, or $6,700.
"The cost of health care is high, and people have started to vote with their feet. In time, there will be a lot of vacant American hospital beds," says Senator Gordon Smith (R-OR), former chairman of the Committee on Aging, who has enlisted the help of the Departments of State; Commerce; Health and Human Services; and Homeland Security to build a medical tourism task force. "But if Americans are going to travel for reasons of cost, they should have some assurance that the services they engage are legitimate, and not some snake oil abroad." Adds Kimberly Collins, the senator's spokesperson, "This is an industry ripe for fraud and abuse."
Saving Big Bucks
If you have surgery overseas, the prices can be staggeringly lower — in some cases, as much as 97 percent. Here's how the numbers stack up in five countries. Note: Most of these estimated dollar amounts were provided by Josef Woodman, author of Patients Beyond Borders, who surveyed hospitals to find averages.
| Surgery: | U.S. | India | Thailand | Singapore | Malaysia | Mexico |
|---|---|---|---|---|---|---|
| Heart Bypass (CABG) | $113,000 | $10,000 | $11,000 | $18,500 | $9,000 | $3,250 |
| Heart Valve Replacement | $150,000 | $9,000 | $10,000 | $12,500 | $9,000 | NR |
| Angioplasty | $47,000 | $9,000 | $13,000 | $13,000 | $11,000 | NR |
| Hip Replacement | $47,000 | $8,500 | $12,000 | $12,000 | $10,000 | $17,300 |
| Total Knee Replacement | $48,000 | $8,500 | $10,000 | $13,000 | $8,000 | $14,650 |
| Gastric Bypass | $25,000 | $6,000 | NR | $26,000 | NR | $8,000 |
| Hip Resurfacing | $47,000 | $8,250 | $10,000 | $12,000 | NR | NR |
NR: This country not currently recommended for this procedure.
The Risks Patients Face
Surgery can go wrong, regardless of the country where it takes place, the hospital where it's performed, or the doctor holding the knife. And, of course, quality of care varies from hospital to hospital, just as it does in America. That's why it's essential for patients to minimize the risks as much as possible by making good choices — something that's difficult to do, say critics of medical tourism, in nations where the standard of care is inconsistent and qualitative measures are often vastly different from those in the States.
"One of the struggles is that there is no data," says Arnold Milstein, M.D., medical director of Pacific Business Group on Health, a nonprofit group that focuses on improving the quality of health care while controlling costs. "All you can say is that there is more uncertainty about quality with this form of care than there is with American care." Dr. Mahal agrees that overseas treatment can be unpredictable. "While the best hospital in New Delhi is on par with some of the best hospitals in the United States, if you start comparing an average hospital in New Delhi to an average one in America, you would find an enormous discrepancy," he says.
Many medical tourists understand that they're leaving the safety net of health-care standardization. "It was scary going abroad. But life is not risk free," says Patty Sanden, from North Bend, OR, who needed a hysterectomy this year and saved at least $13,000 by having it in San José, Costa Rica. She relied on the booking agency MTI to prescreen doctors. Her surgery went well and the hospital staff, she says, "treated me like a celebrity."
Jennifer Schilling, 38, also used a concierge to schedule a hysterectomy abroad, but she did more research than Sanden. Still, she found it hard to get a clear picture. Learning earlier this year that she needed an operation, Schilling called her local hospital in Springfield, MO, to find out how much her stay would cost, apart from the surgeon's fee. "They told me the mean was $30,000, but that it could go as high as $200,000 if there were complications," says the married mother of two, who owns an equipment rental company. Knowing that her insurance had a $5,000 deductible and a 20 percent co-pay, she did the math and drew her own conclusion: "If something went wrong, my co-pay could've been $40,000. I couldn't take that risk." So she contacted MedRetreat. What she learned: Treatment in Penang, Malaysia, would cost $8,000, including the surgery, hospital stay, tests, travel, and 18 days at a five-star hotel.
MedRetreat recommended Suresh Kumarasamy, a surgeon at Gleneagles Medical Center. Schilling went to the hospital's Website and read the doctor's bio, which stated that he had trained in England. She searched other sites in hopes of verifying that information, but she couldn't get the facts nailed down. And although she had a list of his degrees (from his bio and from materials sent to her by MedRetreat), she was baffled by the acronyms, such as M.B.B.S., M.Ob.Gyn., and MRCOG. So she tried another angle: talking to one of Dr. Kumarasamy's former patients (MedRetreat supplied the name and phone number). "I could tell this woman was hard to please, and she thought very highly of Dr. Kumarasamy," says Schilling. Reassurance also came from MedRetreat's destination program manager, an American woman who lives in Penang and volunteers at the hospital.
Once at Gleneagles, Schilling was further impressed when, during presurgical testing, Dr. Kumarasamy told her that she had a heart murmur. "No one in the States had ever caught that," she says, "and he heard it through his stethoscope."
When Good Housekeeping asked Patrick Marsek of MedRetreat to explain the acronyms in Dr. Kumarasamy's degrees, he admitted he didn't know what they meant. "Most patients don't ask these kinds of questions," he said. Perhaps that's because most are accustomed to simply accepting referrals from doctors and trusted family members and friends. But operating overseas, outside one's local medical network, requires much more vigilance.
Marsek promised to investigate the degrees for us (stressing that he would do the same for any patient who asked), and in a later e-mail, he supplied the answers: M.B.B.S. is an Indian Bachelor of Medicine and Bachelor of Surgery degree, achieved after five to six years of study; an M.Ob.Gyn. is the Malaysian equivalent of a postgraduate program combined with a residency in obstetrics and gynecology. MRCOG means that the doctor is a member of the elite Royal College of Obstetricians and Gynecologists in London. But even if a medical concierge delivered this kind of information to a patient, how could she evaluate and verify it?
The first step is to ask the booking agency if they've done any vetting of the doctors and hospitals they propose. Stephanie Sulger, R.N., M.S., director of International Medical Services at MTI, says it's dangerous to research cost and take the rest on faith. "When someone who's desperate for care Googles 'cheap' and 'hip replacement' or 'gastric bypass,' they're likely to go with whatever they find because they've been led to believe that everything overseas is OK. It's not," explains Sulger. She says that the company spends 30 percent of its time researching overseas doctors, checking with the credentialing boards in each country, and verifying that any memberships they claim in important medical organizations are current. She says MTI no longer sends patients to certain hospitals because of concerns about some of their doctors' credentials.
Whatever efforts are made by booking agencies, what's missing is a comprehensive accreditation process by which established medical experts in the U.S. can evaluate foreign hospitals. In America, the gold standard is the Joint Commission, which evaluates some 15,000 health-care organizations (from hospitals to labs). JC has an international branch, Joint Commission International, which started accrediting in 2000. But so far its reach is too limited for its credential to be considered the last word. JCI currently accredits 127 international hospitals and has about 100 others now preparing for review. Foreign hospitals aren't required to apply, and many don't; some of those facilities may be substandard, but others are possibly put off because the process takes most hospitals 18 to 24 months and costs, on average, $30,000. So while the JCI credential is meaningful in judging a hospital, its absence may not be a problem.
Some experts even question the quality of JCI's reviews. "It's very difficult to evaluate the medical training of practitioners and the ongoing quality of facilities outside the country," explains Joel Miller, senior vice president of operations for NCHC.
Consumers looking beyond JCI for endorsements from the U.S. medical community may find themselves in a sea of salesmanship. The key is knowing which claims are legitimate. For instance, on its Website, Wockhardt Hospitals, Mumbai (a JCI-accredited facility in the Wockhardt Hospitals Group) touts its association with Harvard Medical International, a branch of Harvard Medical School. That affiliation is confirmed by HMI, which explains that although the Mumbai, India, hospital is not staffed with Harvard-trained doctors, as some prospective patients might assume, HMI has provided a range of training and education services to Wockhardt, from professional management to systems development to helping the hospital prepare for JCI accreditation review.
But not every hospital's claims are as substantial as Wockhardt's. In July 2007, when Good Housekeeping checked out the Website of the Asian Heart Institute in Mumbai, we found the logo of Ohio's Cleveland Clinic, an elite cardiac-care center. We also learned that the clinic's name appeared on AHI stationery and was engraved in stone at the Mumbai hospital's entrance. All this was news to Cleveland Clinic spokesperson Eileen Sheil, who says that her hospital's only connection with AHI was to consult on purchases of new technology and the use of medical equipment on an as-needed basis. "The Cleveland Clinic is in no way involved with hospital management or patient care at the Asian Heart Institute," Sheil says. The Cleveland Clinic terminated its already limited relationship with AHI in July, and is investigating the hospital's use of its logo. Within a week of Good Housekeeping's conversation with Sheil, the Cleveland Clinic logo was removed from AHI's Website.
Post-Op Problems
Even if all goes well with surgery, patients often have problems later — by which time, the medical tourist is back in the United States and the doctor is thousands of miles away. "It's not as simple as getting on an airplane, having your operation, and coming home," says Miller. "How are patients assured of quality care continuing when they are home?"
Robin Kinney is well aware of this issue. Last November, the 43-year-old tore her anterior cruciate ligament (ACL) playing softball. "I was in terrible pain and couldn't walk," says Kinney, the former manager of a nonprofit company, who is currently single, unemployed, and uninsured. "I called six doctors and explained that I would pay cash up front. But only one agreed to see me." And that doctor refused to provide follow-up care.
A desperate Internet search led Kinney to the booking agency Planet Hospital, and seven days later she was on an operating table at Max Super Specialty Hospital in New Delhi. Although she was scheduled to go back to the United States nine days after the surgery, her doctor recommended she stay off the plane for another five days. But the travel agent wouldn't let her change the ticket. So Kinney boarded her flight on crutches, with her knee in a splint. During the first leg of the trip, she begged the Lufthansa flight attendant to give her one of the many empty seats in business class so she could elevate her knee, but the answer was no. On the second leg, she did snag a first-class seat, but by then had spent hours in terrible pain.
Physical therapy is essential after ACL reconstruction, and once home, Kinney needed help fast. But none of the physical therapists she found in the phone book would take foreign medical orders. Eventually, she called Planet Hospital, which arranged for a U.S. doctor to write Kinney the necessary prescription.
"As far as the technique used to operate on her leg, I wouldn't say it was any better or worse than what I see from the best orthopedic surgeons in St. Louis," says Mark Smith, P.T., A.T.C., the physical therapist who eventually worked with Kinney. "The negative is that she didn't get immediate physical therapy, which is very important to prevent scar tissue from forming. So healing took her about three months longer than it should have." Ten months after surgery, Kinney can now extend her leg without feeling pain. "The care over there is great," she says. "It's coming home that's the problem."
Planet Hospital was quick to address Kinney's issues, both by firing the unhelpful travel agency and by making sure she got the PT prescription she needed. But problems like follow-up care speak to the uncharted aspect of medical tourism, an industry in which the supposed authorities — the booking agencies — have been in business only four or five years at most. Though they often revise company practices to improve service and patient safety (for example, it's now Planet Hospital policy that clients can always change their tickets), companies are still learning on the job.
When Things Go Wrong
For all the patients who offer rave reviews, bad outcomes can and do happen. Jude Jarvis, a 35-year-old mother of three from Scituate, RI, was five-foot-four, 185 pounds, and unhappy about her body. In 2006, she told her sister Elizabeth Wright that she wanted a tummy tuck and a breast reduction, but that she didn't have the $20,000 it would cost. When Wright, who had just heard about a 60 Minutes segment on medical tourism, told her about the overseas option, Jarvis set off to learn more.
One call she made was to Rudy Rupak, founder of Planet Hospital. Rupak says Jarvis told him she wanted not only the stomach and breast work, but also liposuction, a face-lift, and an arm-thinning brachioplasty. Rupak gave her four options: Costa Rica, Panama, Thailand, and India, which was the least expensive. Jarvis chose India.
But she didn't get much further with Planet Hospital. Learning that Jarvis's body mass index was almost 32, Rupak explained that the long flight to India was a bad idea. Air travel increases the risk of deep-vein thrombosis and pulmonary embolism in its various forms (usually a blood clot in the lung), so if a patient's BMI is 29 or higher, Planet Hospital recommends a country that can be reached in less than eight hours. "We truly felt that her weight made it unsafe for her to have so many surgeries and then travel for so long," says Rupak. He also suggested she have the operations in two stages, and in a nearby country like Costa Rica or Panama, even though hospitals there would charge a bit more. "She was very angry and told a Planet Hospital associate that we were only out for the money. That was the last we heard from her," Rupak says.
Jarvis ended up booking her surgery directly with Wockhardt Hospitals, Mumbai. On May 6, 2006, she flew alone to India. Surgery was performed on May 9 by Narendra Pandya, M.D., the same doctor Planet Hospital would have suggested. Four days later, Jarvis died in the hospital from a pulmonary embolism.
More than a year later, Wright says she still doesn't know what went wrong. Did the long flight contribute to the embolism? Was there a problem with her surgery? Could Zelnorm, a prescription drug for irritable bowel syndrome that Jarvis was taking, have helped create the blockage? The FDA pulled the medication from the market in March 2007 because it was found to cause strokes, which are associated with pulmonary embolisms.
Wright doesn't have any answers; all she knows is that if her sister hadn't traveled abroad for surgery, she'd probably still be alive. "I wish I'd never told her about that damned TV show," she says.
"I am very disappointed in Wockhardt," says Rupak. "She should never have been accepted by them. It just wasn't safe." Planet Hospital no longer sends patients to the Wockhardt hospital in Mumbai, which is still JCI-accredited.
Two months after Jarvis's death, another medical tourist died, this time in a Brazilian hospital following a gastric reduction duodenal switch surgery, an alternative to gastric bypass surgery. Her family doesn't wish to publicize her name, so she is referred to in this article as Nancy.
According to a blog she kept on Obesityhelp.com, Nancy, 44, weighed 360 pounds and had been considering weight-loss surgery since 2001. In her blog, she wrote about problems getting health insurance coverage for the procedure, which would cost $29,000 to $35,000. Then Nancy, who lived in Roseburg, OR, learned about overseas operations. "I just can't justify $34,000 here in the States when I can get it done for $10,000 to $15,000 elsewhere," she wrote. She ended up seeing João Marchesini, M.D., who operates in Curitiba, Brazil. His Website claimed that more than half of his duodenal switch surgery patients were American or Canadian. As of May 2007, almost a year after Nancy's death, the Website continued to boast, "The mortality rate related to duodenal switch is zero percent." (The site has since been taken offline.)
On July 1, 2006, Nancy wrote: "Oh my God, this is so flipping real. In 13 days...I can finally join the [weight] losers bench!" On July 12, she wrote: "Well, I'm about ready to leave for the hospital...I will e-mail after surgery...probably not for at least a couple of days." Three days later, Nancy was dead. According to her niece by marriage, Allison Rudolf of Ione, OR, Nancy, like Jarvis, was killed by a pulmonary embolism.
Neither family holds the doctors responsible, so they never considered suing. But even if they had felt differently, legal action would have been difficult. Foreign laws are different, the court systems operate in the local language, and settlements are considered low by American standards. Suing overseas is also expensive, assuming you can find a U.S. lawyer familiar with the host country's legal system.
And then there are cultural differences. "Most countries don't have the litigious environment we do, and that's something every medical tourist needs to consider," says David Boucher, assistant vice president for health-care services for BlueCross BlueShield of South Carolina, which has a subsidiary that covers medical care abroad. Experts speculate that one reason surgery overseas is so much less costly is that hospitals and doctors don't pay as much for malpractice insurance as their counterparts do in the United States.
The lack of legal recourse is a real problem for West Virginia Delegate Ray Canterbury, who has proposed a bill in the legislature that would provide state employees and their families coverage for overseas medical care. (A similar bill has been proposed in Colorado; neither has yet passed.) "The potential for malpractice is one of the biggest hurdles we need to overcome before pushing through legislation that would offer foreign medical care to state employees," says Delegate Canterbury. His plan proposes third-party insurance, which would offer compensatory damages to patients who are disfigured or maimed.
Medical tourism is such a new industry that there will likely be dramatic changes in the upcoming years. But for now, says Dr. Milstein, "people who travel outside the U.S. for medical care are like pioneers in the wild, wild West."
Good data may not exist. Quality of care may be inconsistent. Patients may face language barriers, flight difficulties, or trouble getting post-op treatment. But these are the risks some people are willing to take — and some feel they must take — to get the health care they can no longer afford at home. For patients like Schilling, who was treated in Malaysia, the bottom line is clear: "I'm an American, yet I could never get this kind of care here. I'd go back in a heartbeat."
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