Employers, Insurers Consider Overseas Health Care

Kevin Stewart is recuperating from his liver transplant in Florida. i i

Kevin Stewart, who received a liver transplant in India, is recuperating in Florida's Big Pine Key. Greg Allen, NPR hide caption

itoggle caption Greg Allen, NPR
Kevin Stewart is recuperating from his liver transplant in Florida.

Kevin Stewart, who received a liver transplant in India, is recuperating in Florida's Big Pine Key.

Greg Allen, NPR

Q&A: Preparing for a Surgery Abroad

Faced with rising health care costs, more and more Americans are digging out their passports. But the medical tourism industry is brand new; there's no easy way to find reliable, independent information on foreign hospital and physician standards. With that mind, if you are considering a surgery abroad, what do you need to know?

An Arab family waits outside Bumrungrad International Hospital in Bangkok. i i

An Arab family waits outside Bumrungrad International Hospital in Bangkok, which attracts patients from across the world, in 2005. Saeed Khan/AFP/Getty Images hide caption

itoggle caption Saeed Khan/AFP/Getty Images
An Arab family waits outside Bumrungrad International Hospital in Bangkok.

An Arab family waits outside Bumrungrad International Hospital in Bangkok, which attracts patients from across the world, in 2005.

Saeed Khan/AFP/Getty Images

Maybe you're going to have surgery, a serious but routine procedure like hip replacement, cataract removal, a heart bypass.

Would you prefer to have it done at your local hospital or at one in Singapore, Thailand or Costa Rica? That's a choice Americans are increasingly being asked to make.

"Medical tourism" — traveling overseas for medical care — was first embraced by consumers. But it's now also being looked at by employers and health insurance companies.

The name can be misleading. While there are many people who choose a medical procedure in an exotic locale so they can enjoy the travel experience, medical tourism also includes people like Kevin Stewart. Last year, he learned he had cirrhosis of the liver and that a liver transplant was his only option.

Looking Overseas for Help

Stewart had his own landscape maintenance business in Naples, Fla., but because of high premiums, he had let his health insurance lapse. Fortunately, he had a potential donor — his sister — and he began calling hospitals to see how much a liver transplant might cost.

"It was $30,000 for them to check me out to see how badly I needed a liver. And, if they decided I needed a liver transplant, I should pay them $300,000," he says.

That was more than he could afford.

With his sister's encouragement, Stewart began looking to other countries for medical treatment. He contacted a medical tourism Web site, WorldMed Assist, which researched his situation and came back with two hospitals that could perform the liver transplant — both in India.

Stewart quickly settled on a hospital in New Delhi and a surgeon who, at that time, had already performed 120 similar liver transplants. It was an easy decision, he says, in part because it was really his only option. But others saw it differently.

"Everybody I spoke to thought I was a crazy person. 'Why would you go there ... you're going to get infected, it's a dirty place...' Now I'm certainly happy to spread the word to people that you do have choices. You don't have to lay down and die," he says.

Four months after the transplant, Stewart is doing great — recuperating in the Florida Keys — and looking forward to getting out on his boat for snorkeling and fishing. The total cost of his medical treatment and his travel to India? Less than $90,000 — about one-quarter of what he would have paid in the United States.

'Great Quality, Immediate Service'

It's an extreme example, but by no means unusual. Numbers are hard to come by, but it's estimated that a half-million Americans traveled to a foreign country for medical treatment last year. Many go to clinics just over the Mexican border that specialize in dental implants or lap-band surgery for obesity.

But increasingly large numbers are going farther — to hospitals in Costa Rica, Thailand and India — for hip joint resurfacing, kidney transplants and prostate surgery.

Probably no institution serves more foreign patients than Bumrungrad International Hospital in Bangkok — 450,000 last year alone. Ruben Toral, a medical tourism consultant who works with Bumrungrad and other hospitals throughout Asia, says the appeal is simple: It's about value.

"Great quality, immediate service," he says.

Toral says it's service that "you'd never find in an American hospital or even a European hospital. Price ... is going to be anywhere from one-half to one-eighth the cost of health care in the United States. And access — you can see a doctor when you want to see a doctor. There is no issue of waiting."

Toral and some of the hospitals he represents recently joined with other institutions in the United States and around the world to form a trade group, the Medical Tourism Association.

They are working to bring some order to the rapidly expanding universe of global medical care. One goal is to make medical tourism appealing not just to the uninsured, but also to employers and health insurance carriers.

"If the insurance companies created essentially an international provider network where people could actually choose to go overseas for health care in exchange for lower premiums, lower co-pays, that ... would be a very attractive alternative for corporations who are looking at lowering their health care costs," Toral says.

Interest from Insurance Companies

In fact, many health insurance carriers are looking at medical tourism. A few have already begun to offer it as an option to their members. One of the pioneers is OptiMed Health/United Group Programs, a health insurance carrier that, more than a year ago, began offering medical treatment abroad to its members.

Overseas treatment is offered just as an option, but there are inducements. The company covers all travel and expenses, eliminates the member's deductible and co-pay and now, in some cases, offers to pay the patient $5,000 in cash.

With all that, former OptiMed executive Jonathan Edelheit says medical tourism is still a good deal for insurance companies and employers. "Oh, absolutely," he says. "Because for a heart procedure that might cost $100,000 here in the United States, it might cost $9,000 in Asia."

Edelheit, now president of the Medical Tourism Association, says although several insurance companies have joined his group, most big carriers aren't yet ready to jump into medical tourism. One reason is liability. If there are bad outcomes, Americans who receive medical treatment abroad will find it difficult, if not impossible, to sue for malpractice overseas. Some insurance carriers are leery that might leave them vulnerable to lawsuits.

Another big issue is the quality of care. What assurances are there that a hospital in a foreign country measures up to American standards? Edelheit says his association is working to develop benchmarks that will allow consumers to compare U.S. hospitals with those overseas, measuring things like infection rates, success rates and mortality rates in a hospital.

Edelheit says the benchmarks will allow consumers to know what kind of care they can expect from a foreign hospital.

"They know this hospital has a 3 percent infection rate per thousand people versus this one that has an 8 percent. And obviously, you'd want to go to a hospital that has better care, which means lower infection rates and higher positive outcomes," he says.

Taking on Additional Risk

But as medical tourism grows, Nathan Cortez sees a danger. Cortez, an assistant law professor at Southern Methodist University, is publishing a paper soon on medical tourism. In signing waivers and agreeing to overseas treatment where malpractice lawsuits are impractical, he says, patients should be aware they are assuming additional risk, and he believes they should be compensated for it.

While patients should be free to travel overseas and reap savings if they wish, one consequence may be that people who insist on receiving treatment only in the United States will end up paying more, he says.

"We see this all the time with other industries," Cortez says. "Health care has been notoriously a local industry, and now it's ... succumbing to globalization like other industries have."

Concerns about the outsourcing of American health care jobs have led some unions and employers to oppose medical tourism. But those opponents don't include leading members of the U.S. medical establishment. Both the American Hospital Association and the American Medical Association have looked at medical tourism and, so far at least, they are remaining neutral.

Q&A: Preparing for a Surgery Abroad

A Thai nurse checks blood pressure of a patient from United States in Bangkok.

A Thai nurse checks the blood pressure of a patient from the United States following an operation at Yanhee General Hospital in Bangkok. Saeed Khan/AFP/Getty Images hide caption

itoggle caption Saeed Khan/AFP/Getty Images

Faced with rising health care costs, more and more Americans are digging out their passports.

Numbers are hard to come by, but according to some estimates, as many as 500,000 Americans go abroad each year to get advanced medical care from lower-priced hospitals and clinics in countries like Mexico, India and Thailand.

Even with the costs of travel, accommodation and other expenses, getting these procedures abroad is often cheaper than getting them in the United States. The Journal of Financial Planning estimates that savings may range from 50 to 95 percent of the U.S. cost.

The medical tourism industry, as it's called, is only a few years old, and most tourists make arrangements through special agencies or the foreign hospitals themselves. As a result, it's hard to find reliable, independent information on foreign hospitals' standards, doctors' qualifications, or patients' legal protection.

With that mind, if you are considering a medical operation abroad, what do you need to know?

Q: How do I find out if a foreign hospital is accredited?

The Joint Commission, an American non-profit that accredits hospitals in the United States, has a division that does the same thing for foreign hospitals and other health-care facilities. Joint Commission International uses American medical standards to evaluate foreign facilities. The number of international entities accredited by JCI is expected to grow rapidly in the next few years, from 140 to almost 300. Most are in Asia.

Medical tourism agencies, which function much like other travel agencies, also offer information about doctors' and hospitals' credentials. However, you may want to do independent research if you rely on these agencies, since they have a financial interest in medical travel but don't actually provide health care. It's also important to realize that these agencies aren't necessarily subject to American laws.

There is no master list of foreign hospitals that accept medical tourists, but "most countries are known for a particular category of treatment," author Josef Woodman writes in Patients Beyond Borders.

"If you're seeking cosmetic surgery, Brazil, Costa Rica and South Africa rank among the most popular destinations," he writes. "Dentistry will have you exploring Mexico, Costa Rica, or Hungary. The more expensive, invasive surgeries, such as open-heart surgery or a knee replacement, make a longer trip to India, Thailand, Singapore or Malaysia well worth the cost, time and distance of travel."

Q: Once I locate a hospital, how do I check out a particular doctor's qualifications?

Usually patients work through medical tourism agencies that they find on the Internet, but you can also call a hospital directly. The agency or hospital can then arrange for you to speak with doctors or previous patients on the phone.

Dr. Ann Marie Kimball, a physician and professor at the University of Washington, offers some tips on screening a doctor:

"You can ask other people and you can ask your own physician to check out these physicians," she says. "Obviously, talent and skill are not confined to the United States. There are many talented and highly skilled surgeons working overseas who are well-trained, sometimes trained in U.S. medical schools, sometimes trained in Canadian, British, Indian medical schools."

Kimball agrees it is more difficult to check out an international surgeon. "But often, surgeons know surgeons, and if they're members of the same professional organization, they may well be aware of one another's reputation," she says.

Q: Will my insurance cover medical procedures performed abroad?

Generally, no. Although some major U.S. insurers — such as Aetna, Cigna and Humana — are increasingly considering it. And a few smaller companies do offer incentives to go abroad. Insurers are attracted to medical tourism by the low cost of these procedures — sometimes one-tenth or one-twentieth the cost of their American counterparts. But they are often more concerned that they'll face lawsuits if something goes wrong at hospital outside the United States. Call your insurer's customer service line to see if you're covered for visits to hospitals abroad.

Q: How much will it cost?

Prices vary widely. Some facilities' Web sites list the prices of various procedures they offer, but hospitals increasingly require prospective patients to fill out an online form and receive a quote, much like life insurance.

Quotes from different hospitals may be hard to compare, since the services offered vary from facility to facility. For instance, one hospital's quote may only cover the procedure itself, while another hospital's quote may include airfare, hotel, rehabilitation and follow-up care. Taxes and tariffs may also be left out. Ask an internationally based hospital for a breakdown of its quote before proceeding.

Woodman suggests a $6,000 rule: if your procedure would cost more than $6,000 in the United States, you would likely save money — possibly more than $1,000 — by traveling to a foreign hospital, including all other costs.

And don't forget about the non-financial costs: being far from home and family, taking an uncomfortable flight and missing work. If the medical procedure doesn't go exactly as planned, these may take longer than you expected. To make these risks easier to swallow, Woodman recommends, consider bringing a partner on your trip.

Q: If something goes wrong, what recourse do I have?

It depends on how you got there. The medical tourism business remains a fragmented one, with no clear authority in most cases. While Americans can rely on domestic malpractice laws and medical standards, these aren't necessarily effective in other countries.

If you paid a medical tourism agency to find a doctor, make travel arrangements and get you a hotel, they may be liable in some cases. If you didn't use an agency, you may choose to seek damages from the hospital or the doctor. But be advised that the host country may have strict laws against medical lawsuits, or it may have a legal system that takes years to hear your case.

Q: In general, what rules should I follow if I'm considering a medical trip abroad?

Do your homework and do it well in advance. Read as much as possible about the hospital and the doctor you're considering. Talk to former patients and others who can vouch for the quality of the hospital. And don't assume it will be a cakewalk.

"It's real important not to confuse it with a luxury vacation or a spa vacation," Dr. Kimball says. "It's really not a vacation. It's very serious, and to be taken with lots and lots of research, as much as you can do."

Kimball also says you should clue in your doctor, so that even if he or she disapproves of your trip, your post-operation care in the United States will go more smoothly.

And while low cost is a nice attraction, it's not all that matters.

"Looking at the finances is just a piece of the puzzle," she says. "Obviously people are more concerned about their own safety. And so I would say the best rule of thumb is, don't only go for the bottom line. Consider very carefully each step of the procedures and each step of the recovery, and whether your own doctor's going to be on your side and helpful, in terms of helping you sort out those risks, and welcoming you back to the post-operative period with good care and access. It's a complicated thing — I don't think it's to be taken lightly."

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