Medical Tourism Creates Thai Doctor Shortage

A Thai nurse takes care of a patient at Thailand's Bumrungrad hospital.

hide captionA Thai nurse takes care of a patient from the Middle East at Thailand's top private hospital, Bumrungrad International.

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Members of the Thai navy row a Royal barge on the Chao Phraya River in front of Siriraj Hospital i i

hide captionMembers of the Thai navy row a Royal barge on the Chao Phraya River in front of Siriraj Hospital, Bangkok. Siriraj, a public hospital, was founded by the royal family more than a century ago to provide free care to the Thai people.

STR/AFP/Getty Images
Members of the Thai navy row a Royal barge on the Chao Phraya River in front of Siriraj Hospital

Members of the Thai navy row a Royal barge on the Chao Phraya River in front of Siriraj Hospital, Bangkok. Siriraj, a public hospital, was founded by the royal family more than a century ago to provide free care to the Thai people.

STR/AFP/Getty Images

Millions of people come to Bangkok for medical care. They get everything from face-lifts to heart-bypass operations. These medical tourists have helped boost the Thai economy, but there's a downside. Doctors in Thailand have become so busy with foreigners that Thai patients are having trouble getting care.

When medical tourists come to Bangkok, they usually go to places like Bumrungrad Hospital. It's a private facility, downtown, near the fancy hotels. It has a sushi bar, interpreters who speak Arabic and Mandarin, and VIP suites with marble bathrooms.

Most Thais can't afford it. They're more likely go across town to Siriraj Hospital, along the banks of the Chao Phraya River.

Doctors in Demand

Siriraj was founded by the royal family more than a century ago to provide free care to the Thai people. It treats more than 2 million patients a year.

The outpatient waiting room looks a bit like Grand Central Station. On a very hot day. With no air conditioning.

Hundreds of patients are squeezed onto old wooden benches. Many more are slumped in wheelchairs or lying on gurneys.

Malai says she has come in from the district of Phetchaburi because she feels sick and her legs hurt. She also has hepatitis. She left her home at 3 a.m. to travel three hours to the hospital.

She will probably have to wait several hours to get two or three minutes with a doctor. Then she'll wait some more for test results or a prescription. Malai says she won't get home until 9 p.m.

A recorded message asks for patience. It's a constant reminder that Siriraj doesn't have nearly enough doctors.

And neither do other hospitals that accept people covered by Thailand's basic health plan.

The Pay Factor

The problem is money. Doctors don't get paid much for working at public hospitals, so many won't. The ones who do tend to moonlight at private facilities.

Dr. Suwit Wibulpolprasert is an adviser to the Thai Ministry of Health. He says even public doctors depend on private patients.

His wife, for instance, is a radiologist who works five days a week at a medical school and then at a five-star private hospital on Saturdays.

"What she earns in one day per week is about almost three times what she earns in five days at public medical school. So we survive," he says, laughing. "We serve the public at the same time we serve the private."

Wibulpolprasert's wife is trying to follow the teachings of Thailand's Prince Mahidol. In the 1920s, the prince called on Thai doctors to treat the poor as they would their own families.

But Wibulpolprasert says many young doctors don't feel this obligation.

After medical school, most of them have to work in a provincial hospital for at least a couple of years. Wibulpolprasert says once that's done, they tend to head for the private sector.

"And this is the so-called river of no return," he says. "They never go back."

The doctor shortage isn't a new problem for Thailand.

During the Vietnam War, Thai doctors left in droves to work for the U.S. military. Then they started leaving for other countries, where they could earn more money.

The shortage gets worse every time a doctor leaves the public sector to take care of medical tourists.

Other Avenues for Revenue

The river of no return is flowing swiftly at Siriraj.

Dr. Damras Tresukosol is a cardiologist here. He says the doctors he loses are often the most skilled.

"I just heard that one of my colleagues resigned from this hospital. He is one of the best cardiac surgeons who can perform congenital heart operations," he says, slumping a bit. He looks around the small meeting room. "I'm very afraid ... that if we don't change anything, good doctors will leave and work for private."

So Tresukosol is trying a radical experiment just outside the meeting room.

High above the teeming outpatient department, Tresukosol has created a new center for cardiac care.

The fifth floor is like one of those swanky private hospitals downtown. Tresukosol notes the television, refrigerator and sofa. There's an entertainment area for relatives. It's private, modern, home-like.

"So that's the idea," he says.

There's even a marketing slogan.

"This is our motto: We provide good hands and better hearts," Tresukosol says, laughing.

The idea is simple: Attract some private patients to Siriraj, so doctors here can earn more money without leaving for another hospital.

Siriraj isn't focusing on medical tourists. The cardiac unit hopes to get Thai people willing to pay a bit extra for special care and no waiting, or expats who want more amenities and privacy than they would get in a typical public hospital.

It's a big leap for a hospital with a royal mandate to care for the common person. But Tresukosol says the new unit will help fulfill that mandate.

"We have our own motto. The motto belongs to the king's father. His motto is to treat the poor as ourselves," he says. "But to survive in this globalization, we have to look forward and try to bring in more patients who are affordable to this unit, to give us some revenue to treat the poor."

Attracting Patients

It's too soon to know whether the cardiac unit will make money or keep doctors at Siriraj. But it has brought some new patients.

Robert Morris and his wife retired to Thailand a few years ago. When he began having heart problems, he came to Siriraj.

"Right now, I'm a post-pacemaker implantation patient. It was implanted yesterday at 1 in the afternoon," he says.

Morris is not exactly the average patient. He used to run a big Veterans Affairs hospital in Denver. And he knows a lot about Siriraj.

"This is the facility where the king would come. If the king can come here, I certainly can come here," he says.

Even with more patients like Morris, Siriraj will never be able to pay doctors as much as places like Bumrungrad.

But Tresukosol says the private patients will make it easier for doctors to follow the lead of Prince Mahidol.

The prince left Thailand to get an MD at Harvard. Then he came back to spend his life caring for the poor.

Produced by Rebecca Davis.

Q&A: Preparing for a Surgery Abroad

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

hide captionA 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

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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