Tuesday, December 23, 2008

Our Commentary in FT - Comprehensive Healthcare In US Can Be Realized

On Dec. 23rd the Financial Times published our letter / commentary on the need to import doctors and export patients to alleviate shortages and cut soaring costs. These trade aspects of healthcare haven't yet been mentioned in proposed Obama reforms and incoming Healthcare Secretary Tom Daschle's recent book. Here is our published content (the FT uses "English English" and not "American English") :

From Prof Jagdish Bhagwati and Mr Sandip Madan.

Sir, In his characteristically insightful fashion, Clive Crook ("The long road to healthcare reform", December 15) alerts us to the problems that await the likely approach to comprehensive coverage of healthcare by Tom Daschle, the incoming US secretary of health and human services, as suggested by his recent book on the healthcare crisis.

But the fact that Governor Mitt Romney's similar reform in Massachusetts ran into the difficulty of finding doctors and other healthcare workers for the newly insured, and that Governor Arnold Schwarzenegger had to abandon similar efforts in California because of high costs, raises the question of why Mr Daschle and President-elect Barack Obama have not yet recognised that the systematic and comprehensive embrace of international transactions in medical services can make a big impact on both these problems.

Today, many foreign hospitals and physicians offer a world-class service for a fraction of the cost in the US. Expensive yet standard procedures with short convalescence periods, including heart operations and joint replacement surgery, are candidates for such treatment abroad.

By our estimates, 30 such procedures, costing about $220bn in 2005, could have been undertaken abroad. The "import" of medical services in just a quarter of those cases would have implied a saving in medical expenses of between $40bn and $45bn.

But the scarcity of medical professionals is equally crippling. Under President Lyndon B. Johnson's Great Society, a selected class of foreign doctors were allowed to "stay on" provided they worked for specified periods in under-served areas. The time has come to expand such programmes. We have recently suggested several ways this could be done, while amending the US immigration policy accordingly.

These programmes, "exporting patients" and "importing doctors" as one of us proposed almost 15 years ago, are now essential if comprehensive coverage of healthcare is to become a reality rather than simply an ineffective reform seriously undermined by shortages and high costs. Once you add the savings from online diagnostics and the reduction of administrative costs (conservatively estimated currently at $500bn annually) through further outsourcing of administrative services, the prospects for easing scarcities and costs are even more inviting.

But all this will involve getting over the jaundiced view of international trade that afflicts most of the new Democrats. Will they choose de facto protectionism, masquerading as "fair trade", and sacrifice the invaluable opportunity presented by possible international transactions in medical services? Or will President-elect Obama truly give us genuine leadership and have Mr Daschle override the anti-trade and medical lobbies that hold up effective healthcare reform?

Jagdish Bhagwati,
Professor of Economics and Law, Columbia University
Senior Fellow, Council on Foreign Relations

Sandip Madan,
Founder, Global Healthnet

Copyright The Financial Times Limited 2008

Saturday, November 22, 2008

A Common Doctor Blind Spot

Patient alert: Many doctors seem to have a blindspot while treating infections. This can subject patients to needless agony or worse. I have personally observed this at least half a dozen times in India and the US, and some cases ended very badly. In all of these the patients were intensively treated with all kinds of strong antibiotics, to no avail. Here they are in chronological order:
  1. Over forty years ago my father's uncle suffered a slow and agonizing death from virtual starvation after being hospitalized and then released. He refused to eat anything, and by the time they figured out why, it was too late.
  2. My brother Kaku as an infant was afflicted with this infection and suffered for weeks after a hernia operation. It even transferred to my mother who was breast-feeding him. Finally, a very good and experienced doctor diagnosed the problem and it disappeared quickly.
  3. Vivek from my college and subsequently my IAS batchmate in HP had a severe illness in the late 70's that landed him in one hospital in India and then another for several weeks. He had high fever, loss of appetite, yellow eyes and other symptoms of hepatitis that had doctors stumped since he did not respond to conventional treatments. Starting from a healthy body weight he lost about forty pounds in that time before doctors in India's famed AIIMS hospital correctly identified the infection. They then quickly (and easily) treated him, bringing him back from the brink.
  4. In the late 80's my friend Raj was hospitalised in LA for several days with high fever and other symptoms that defied any treatment. Finally, a doctor of Indian origin happened upon his case, asked him one very relevant question, then ordered a test that confirmed that doctor's suspicions and prescribed medication that rapidly cured Raj.
  5. About 10 years ago my young cousin Pavan in the US who was a medical student had a tonsillectomy. A few days later the pain in his throat was so acute despite all the medicines he received that he couldn't eat. Based on her experience (and high intelligence) my mother who has no medical background guessed at the problem and asked Pavan's family to bring it up with his doctor. The doctor after needless delay finally listened and Pavan was treated, but his prolonged suffering caused him to miss his medical board exams that year.
  6. Just last month my father-in-law (Daddy) was recovering from two major surgeries at Inlaks hospital in Pune, including complications of pneumonia and hospital acquired infections. His lungs cleared and surgical wounds healed after a strong regimen of antibiotics, but he continued suffer from cough and persistent throat irritation. He couldn't sleep, asked to gargle every 15 - 30 minutes even at night. The Inlaks doctors ordered more antibiotics and tests and thought the irritation was due to residual infection in the breathing passages, as well as the feeding tube that was subsequently inserted because Daddy wouldn't eat or drink. But the problems was as bad or worse for several days after the feeding tube was removed and he was taken back home. Then I had Dr. I examine Daddy at home. Dr. I is very intelligent and sought after though he doesn't have quite the fancy qualifications of the Inlaks doctors. He had Daddy open his mouth wide, depressed his tongue and peered at the back of his throat with a flashlight. That was enough to provide the answer and clearing the condition in two days, though this was after two weeks of avoidable suffering and debilitation.
There is a common thread in all these cases. The doctors did not consider anything beyond bacteria and viruses as the cause of the infections, or simply ascribed the problem to "weakness" or irritation.

But in four of these cases at 1, 2, 5 and 6 above involving my great-uncle, brother Kaku, cousin Pavan and Daddy respectively the culprit was oral fungus, commonly known as thrush. The "good" bacteria in the oral cavity normally keeps this fungus in check, but antibiotics can kill this good bacteria. Then this very painful fungus infects the delicate lining of the oral cavity and typically shows up as white spots (though these may not be visible in the esophagus.) Once diagnosed, thrush is easily and rapidly treated. But if doctors who don't catch on and simply give more antibiotics can make the problem worse instead of better.

In case 3 involving my colleague Vivek, the culprit was amoebiasis where it was the amoeba that had invaded the liver. Again, while antibiotics don't work at all, anti-amoebic medications rapidly clear the condition - provided the doctors make the correct call.

Wanna guess what Raj had come down with in case 4? Well, it was malaria. The American doctors did not have this on their radar as it rarely occurs in the US. But the Indian doctor asked Raj if he had been abroad recently, and when Raj mentioned his recent trip to India, the doctor asked for his blood to be tested for the malarial parasite, and viola!

The takeaway: it seems to be a fairly common doctors' blind spot. If conventional treatment isn't working ask your doctor early on if he / she has considered and ruled out non-bacterial and non-viral infections like those caused by fungi, amoeba and parasites.

Friday, November 14, 2008

Hospital Drug Deals

My in-laws' lengthy hospitalization at Inlaks in Pune exposed me to the gamut of practices and attitudes of the doctors prescribing drugs. Most of my observations are applicable to medical practitioners elsewhere in India and the world, including in the US. An eye-opener for me is how largely unseen doctors like pathologists can steer expensive drugs to patients.

But first the main takeaway: it can help a lot to seek multiple inputs, even informally, especially when expensive drugs or treatment are involved. I managed to identify some good and caring doctors and asked them questions like, "If our patient were your own parent, then what would you do or advise?"

As elsewhere, the Inlaks doctors can be divided according to their prescribing behavior into three types.

Type 1 had close ties with the pharma reps who frequent hospital hallways and waiting areas. These doctors aggressively prescribed expensive brand name drugs (when cheaper generics or substitutes were available), and especially so if you appeared to be a patient of some means. My in-laws were regarded as such because Anita and I live in the US.

Type 2 were the bystanders or silent collaborators of the Type 1's. They didn't actively push the most (unnecessarily) expensive drugs themselves, but tended to concur with colleagues who did, when specifically pressed on the issue, or consulted for a second opinion.

Type 3 were the ones I truly liked and respected. They were strongly guided by their patients' physical as well as financial well-being. They recommended expensive drugs and treatments if they felt we could afford these, AND if these had significant advantages over cheaper options. They also laid out any trade offs fairly. More importantly, they were uncomfortable enough with the behavior of Type 1's to be willing to call them out.

My sense of the Inlaks doctors is that about 20% of them are Type 1, 70% are Type 2 and 10% are Type 3. Dr. Y, a Type 3 whom I came to like a lot wryly noted that most doctors will support their colleagues because they expect to be similarly served when their own actions are questioned. That's why there are so many Type 2's, apart from this being the path of least resistance.

I had noteworthy experiences with some Type 1 and Type 3 doctors.

I regretfully categorized Dr. R as a Type 1 because he otherwise had many positives. He was highly experienced and competent, with a great bedside manner. It was his quick conclusion that Daddy may need emergency surgery, his ordering immediate tests and alerting the surgeon Dr. P that helped saved Daddy's life. Dr. R also sized up Mummy's condition and treatment well. But he spent much more time with pharma reps than his colleagues did. He prescribed a lot of expensive drugs for Daddy that his colleagues felt were unnecessary, or where cheaper substitutes could have worked as well. It's possible that Dr. R genuinely believed in the greater efficacy of the more expensive options, but I sought other opinions to settle nagging doubts.

It was also revealing to see how the Inlaks pathologist Dr. A and his staff from behind the scenes could foist expensive drugs on to patients. Their role may or may not have been in concert with others like Dr. R. Dr. A performed culture and sensitivity tests on Daddy's sputum and other samples. In this, the harmful bacteria present in the sample is cultured for 2-3 days and tested with various antibiotics to see which ones kill it and should be given. The only thing is, Dr. A only tested some of the costliest versions of some drug categories, and omitted the cheap ones that may have worked just as well.

Such practices create broader problems that go beyond draining patients financially. You, see, a lot of these costly new drugs have been introduced to combat germs that are resistant to the cheap conventional ones. They should be sparingly used only when others don't work, or else we'll quickly end up with bacterial strains that are resistant to the new drugs as well.

Case in point: Dr. A's lab tested tigecyclin to combat Daddy's infection caused by the pseudomonas bacterium. This tigecyclin is a tetracyclin-variant drug patented by Wyeth. It was shown to work, but costed $500 - $700, and they never tested for basic tetracyclin or its off-patent versions like doxycycline that cost as little as $20.

I learned about this only because I routinely sought out the opinions of other doctors, two of whom turned out to be Type 3's. One was Daddy's surgeon, Dr. P whom I've talked about in the previous post. The other was Dr. Y in the ICU who was passionate about his patients and visibly worked up over any instances of their inadequate care by the hospital staff.

I asked Dr. A why the much cheaper alternatives to tigecyclin were not tested on Daddy's sputum sample. Dr. A's unsatisfactory response was that he stocked a limited number of drugs for testing, and that his lab "did not concern itself with the costs (of the drugs)." When I expressed my dissatisfaction he agreed to test a fresh sputum sample against drugs that other doctors suggested, like doxycyclin, so I had a fresh sample submitted. But we still had to start Daddy's treatment with the costly tigecyclin since we couldn't wait another 2 - 3 days for the new culture and sensitivity results.

Then Dr. A quietly "rejected" Daddy's new sputum sample as being insufficient in quantity and discarded it without testing. By then it was too late to test another sample since Daddy's tigecyclin treatment had already started and killed off the invading pathogens.

I'm convinced Dr. A acted this way to avoid being exposed if the cheap doxycyclin turned out to be just as effective as tigecyclin. I voiced my concerns to the Inlaks Medical Superintendent who oversees all medical matters. She promised to thoroughly look into these practices though I wonder if anything came of it.

What I do know is the immense value of identifying and dealing with Type 3 doctors. I relied on four of them at Inlaks - apart from Dr. P and Dr. Y, there was the head of surgery Dr. L and orthopedic surgeon Dr. D. Even though we ended up using tigecyclin we were spared other unnecessary treatments.

But being a Type 3 isn't easy. I could see the pressure on Dr. P who was Daddy's attending physician. Guided by his convictions Dr. P would cut out treatments (especially costly ones) that he felt were unnecessary. This often put him at odds with more senior colleagues like Dr. R who could impact his professional career, yet he followed his conscience. I hope he and others like him are appreciated and do well.

Sunday, November 2, 2008

Medical Blunder and its Aftermath

We faced this situation while in India last month: How to react when a dedicated and otherwise competent doctor makes a grave mistake that puts the life of your loved one in limbo?

Our spirits were high on October 1st. It had been almost nine days since my father-in-law (Daddy's) emergency surgery for a ruptured duodenal ulcer. Anita had joined me in Pune, and my mother-in-law (Mummy) was also doing well in an adjacent private ward in the same Inlaks Hospital. Both were to be sent home the following day.

Daddy's surgeon Dr. P had said that the first 6-7 days were the most critical in Daddy's case. This is because the sutures to repair the large perforation of the duodenum are very vulnerable to the strong acids in the stomach, and can typically give out by day 6. If they hold past that, then the prognosis is very good. Daddy was now past that critical period. He had some problems with cough, pneumonia and weakness following the surgery, but this was under control and considered normal for someone of his age who was inactive after a major surgery.

Daddy's IV lines were removed and similar preparations were made for his urinary catheter as well. Dr. P came in and removed the external staples that had held Daddy's almost 2 feet long abdominal incision together. He then urged Daddy to try and resume normal activities including walking as quickly as he could.

An hour later things went terribly wrong. Daddy was coughing hard, and as a result suffered a burst abdomen, meaning that his recently stitched abdominal wall gave out, spilling out some of his insides. Anita raised an alarm and Dr. P. was there within five minutes. He and his juniors hastily tended to the gaping wound, temporarily taped it up, assembled a surgical team and began an emergency surgery within 45 minutes to repair the damage.

The cause of the problem? Daddy is 89, and many of Dr. P's colleagues told us that they'd have not removed the staples for at least 12-14 days after the surgery (instead of the nine days as happened here) and have taken other precautions to protect the healing wound.

The trauma of this second surgery and its consequences placed Daddy's life in the balance for the next couple of weeks. Apart from blood and fluid loss his complications included pneumonia, kidney malfunction, severe hospital acquired infections and heart complications. He was in pain and delirious or semi-conscious for several days. Anita and I cancelled our flights back to the US and postponed subsequent programs in this period. Fortunately, Daddy pulled through, slowly recovered and is now recuperating at home.

Despite his blunder my relations with Dr. P and his colleagues remained warm and cordial. I have repeatedly been asked two questions. First, did I genuinely harbor no ill will towards Dr. P, or did I just mask my true feelings? Second, had this happened in the US, would we have sued and made Dr. P pay heavily for his mistake?

To the first question, I obviously very much wish that Dr. P had played it safe and none of this had happened. But after it did, I still had good feelings about him. We continued to have an easy relationship and I'd even joke about the colorful shirts worn beneath the white coat of one of his cheery-faced residents when they'd visit us in Daddy's room. Here's why:
  • I believe Dr. P's prompt action and skill during the first surgery on September 22 was a big factor in enabling Daddy to pull through. So I attribute Daddy's being home and improving today to Dr. P's initial action
  • Dr. P is overall an accomplished surgeon who is also very responsive. Like many of his colleagues (and not at all like in the US) he had given me his cell phone number at the time of the first surgery and was directly accessible on that when I needed him. (Of course I tried not to abuse this privilege)
  • I perceive a big difference between negligence that may come from not putting in the required time or effort, and "just" a misjudgement. I knew that Dr. P never lacked for sincerity, dedication to Daddy's welfare, or hard work. His unfortunate miscalculation in removing staples prematurely stemmed from a concern about their continued insertion causing a surface infection. I'm sure the consequences will guide his future judgement and help other elderly patients
  • We were fairly high profile at Inlaks (partly because it is rare for both husband and wife to be simultaneously checked into adjoining deluxe wards, and that too by a son-in-law visiting from the US.) Dr. P's mistake was widely known among his colleagues. He paid enough of a price in that sense without me raising the subject with him
  • Dr. P as a person was decent, caring and straightforward. He was uncomfortable when other doctors tending to Daddy prescribed medications that he felt were unnecessary or even needlessly expensive (yes, some of that pharma - doctor linkage seemed to exist here, too.) As coordinating physician he struck off some of these medications or expressed reservations about them, even at the risk of running afoul of his colleagues. I felt I could trust his commitment and intentions
  • Once the second surgery became necessary, Dr. P did everything necessary to reduce its risk. General anesthesia for a second time in a frail patient is a major risk, so he performed this surgery using spinal tap and local anesthesia. He also got his team to waive overtime charges for performing it after hours. He closely monitored Daddy's condition and incessantly advised and encouraged him

Coming to the second question, how would we have acted had the same lapse occurred in the US? We wouldn't have sued Dr. P for all the reasons above. A sued physician pays a huge price even when he is fully insured. This price is in terms of damage to his record and reputation, the distraction of defending a lawsuit, and increases in future premiums.

However, in the US the extra cost following the second surgery may have exceeded $100,000 even at negotiated rates. A substantial chunk may have been payable out of pocket and I would probably have asked the hospital to waive or substantially reduce this. At Inlaks in India the extra charges only came to about $3,500. Given how everyone pulled so hard for Daddy's recovery I didn't seek any reduction in this. In fact when it was Daddy's time to leave he asked me to give some gifts to the staff that had attended to him so well.

Tuesday, October 28, 2008

Long Stay in an Indian Hospital

I have been out of blog circulation for a while, having just returned from a five-plus week unscheduled trip to India. Anita joined me for three weeks in this period. We spent all our day time hours and half the nights as well in an Indian hospital in Pune where both of my parents-in-law were admitted. In the process I learned a lot about one of the many decent hospitals in India that would not make the cut as a medical tourism destination. Here's how it happened.

We heard in mid-September about how my mother-in-law's (Mummy's) health condition worsened after she was bedridden after a couple of falls in the bathroom. She also had difficulty swallowing and stopped eating. The doctor making house calls suggested that she be moved to a hospital for extensive tests and possible treatment. The only way we've moved her out of their second story apartment that lacks elevators is by stretcher and then transported her by ambulance.

My father-in-law (Daddy) simultaneously developed high fever caused by a suspected viral infection. This was followed by side effects of some nasty medication that was prescribed, but we expected this to pass relatively quickly.

Since Anita and her two brothers are all living in the US I left for Pune for what I thought would be a short trip to have Mummy and Daddy checked out and treated. My direct flight on Delta Airlines from JFK to Mumbai was surprisingly comfortable and I headed straight to Pune by road, arriving there within five hours.

While Pune doesn't have JCI accredited hospitals popular with medical tourists, it does have some decent private ones. The three we considered were Jehangir (now owned and run by the famed Apollo group), Ruby Hall (aka Grant Foundation) and Inlaks & Budhrani (run by the charitable Sadhu Vaswani Mission.)

The former two are reputedly more posh and professional, but I settled on Inlaks on the advice of two of my in-law's relatives who said (a) the doctors and staff there are more caring and less driven by profit, and (b) this hospital is run by the Sindhi community to which my in-laws belong, and they'd have more access and attention from the top operatives if this is needed.

My in-laws were admitted to Inlaks just a day apart. Contrary to expectations Daddy's case turned out to be far more serious. He had a large perforation of a duodenal ulcer that was building for years but one we were all unaware of. At age 89 he went through two emergency surgeries nine days apart, which were the first in his life. He spent 25 days in the hospital, and his situation looked grim for quite a bit of this time.

Fortunately, Daddy and Mummy are now home and recovering well. Here are some notable aspects of our experience:
  • The hospital costs were very low by US standards. Daddy's 25 day stay in a deluxe single occupancy room, a score of specialist consultations and two surgeries could have easily cost $200K in the US, even at negotiated rates. At Inlaks it came to about $6K. Similarly, Mummy's 19 day stay and treatment cost about $1,600.
  • In addition to these hospital costs, I also for good measure engaged round the clock help-maids (called "maussis" or "aunts" who help clean and care for the patient) privately for both Daddy and Mummy. They cost a total of about $20 per day and made things a lot easier.
  • A lot of the hospital staff was very caring. The nurses and aides would call elderly patients "Uncle" or "Aunty." Those in the ward would visit Daddy in the ICU the times he was moved there just to see how he was doing. When the time came somewhat to our amusement Daddy was reluctant to leave the comforting cocoon of hospital care.
  • I came to know many of the doctors and administrators, and developed distinct impressions about them. I was struck by the competence and humanity of a sizable number of them.
  • The hospital adjoins the Osho ashram founded by Swami Rajneesh (first made famous by the Beatles who visited it decades ago) and is popular with many Western visitors. I found several of them coming to Inlaks for medical attention and chatted with some of them. They seemed happy with the care overall. That said, I don't consider this hospital suitable for medical tourists, who should expect a more upscale, sterile and professional environment. But if you're not too choosy, you get decent care and can't beat the price.
  • A lot of the nurses had very arduous tasks and often seemed to be understaffed and under stress. I was surprised at how little they were paid - netting about $150 a month in cash or even less. There seems to be a strong case for paying them much more without hurting financial viability.
  • Anita has a phenomenal extended family. I joke that when I married her I didn't realize I'd get such good relatives as dowry. Her cousin Rita insisted on coming from Mumbai to Pune with maid in tow for 5 days and was invaluable in taking charge of Mummy's care in hospital while I dealt with Daddy's situation. Another set of cousins Ashok, his sister Indru and her husband Gul (who own the Sun-n-Sand hotel chain) came from Mumbai to visit. They gave us the penthouse suite of their Sun-n-Sand Pune 5 star deluxe hotel (located less than a mile from the hospital) and full run of all facilities and an army of liveried staff through our stay there. Gul specially called and Ashok threatened to "kill me" when I protested I couldn't accept such lavish help. But it made a huge difference. Then there's Meena and her parents Hira Uncle and Dru Aunty (Mummy's sister) who were always there with help and advice. The list goes on and we're blessed.
I intend to describe some aspects in more detail in the days to come. It's good to be back in the US. My brother-in-law Prakash who lives in Pittsburgh is now with my in-laws for the past few days and doing a great job caring for and settling them down.

Wednesday, August 20, 2008

Exercise Don'ts And Dos

I know, I know. Diet and exercise is the nauseatingly repetitive advice for best warding off many health problems. And unlike claims by some enthusiasts about the "high" you enjoy while exercising, the best part of my workout by far is when it is all over for that day.

Exercise for me has been purely an obligatory part of physical maintenance, and I used to follow a home regimen some days a week. So if you've been having problems overcoming inertia or a hectic schedule I'll encourage you to be more active. But trust me, I feel your pain.

Fifteen years ago my (then future) sister-in-law Deanne first helped overcome my reluctance to enter a gym. She introduced me to some exercise equipment and I've been a fairly regular gym goer since then. I'm glad it's paid off, but I've had sporadic problems because of wrong exercises or poor form that I learned about and corrected only subsequently.

But today I happened upon this excellent article with illustrations on WebMD.com about nine bad or least effective exercises, and better ones in their place. I'm guilty of at least three of those nine lapses, and wish I had seen this article earlier. It's certainly worth a look.

For those who don't like the concept of gyms or using exercise equipment there's also this useful article about seven "most effective" exercises that can be done at home. Five of these require no equipment at all and in the other two dumbbells or simple home objects can substitute for the barbells shown. Of course there are several lists of "best exercises" featured in magazines and other publications, and this is just one of them.

Finally, here's the Wikipedia description of the classic 5BX / 10BX system for men and women (with a link to download it) that takes just 10 - 15 minutes a day. I used this for many years after it was taught early in my service career, and still like to go back to it from time to time.

Wednesday, July 23, 2008

Ignore Obama Critics (At Least) On This

This is a dual surprise for me. First, the New York Times (NYT) today questions some of their favorite candidate Obama's assertions. And second, these criticisms are misplaced and Obama is actually on target this time. Let me explain.

I think Obama's healthcare proposals have many shortcomings, including not mandating coverage as pointed out by Paul Krugman way back in February. But I fully agree with his stand in today's article "Health Plan From Obama Spurs Debate."

Put simply, Obama vows that if elected President he will lower projected healthcare costs by $200 billion or 8% by the end of his first term. He backs this with some calculations and analysis put forward by his healthcare advisors including three Harvard professors.

Yet the article goes on to say that pundits and "analysts question whether significant savings would materialize in as little as four years, or even in 10." I'm wondering about these naysayers and the kind of mental straitjackets they've put on their thinking and analysis. I believe that an 8% reduction in health costs in 4 years' time is very conservative and easily achievable.

In our May 27, 2008 OpEd in the Wall Street Journal or its fuller version we describe the potential gains from free trade (or globalization) in healthcare alone. The US can save $70 billion annually from further offshoring of remotely delivered administrative and diagnostic services. Exporting patients for 30 major procedures suitable under medical tourism that cost $220 billion in the US can save $40 billion. Another $40 billion can be saved by alleviating the artificial scarcity of doctors by importing foreign trained doctors from accredited institutions abroad. So the annual savings tally just from free trade in services comes to $150 billion.

Now factor in the savings from allowing drug imports, curbing "lock in pricing" abuses or overcharging by PBMs, and for Medicare to directly negotiate drug prices. Assuming a 20% reduction in drug prices (which is realistic, given that drugs in Europe cost almost half of what they do in the US) will yield savings of $50 billion.

So here you have it. $200 billion of reductions without even tapping the huge savings from reduction in unneeded procedures, better electronic record keeping and tort reforms that cut down on defensive medicine.

Thursday, July 17, 2008

Theatrics In Medicare Bill, Bush Veto, Override

As Paul Krugman said in his July 11th column in the New York Times, the passing of the Medicare amendment bill by Congress was a welcome development. McCain was on the wrong side of the issue here and unsurprisingly a prominent absentee in the senate vote.

In a move that plainly sought to protect special interests, President Bush followed through on his earlier threat and vetoed the bill. But Congress moved quickly for a dramatic override of Bush's veto, so the bill has now become law. Apart from preserving the doctors' Medicare fee rates the bill reduces the subsidies payable to health insurers who offer Medicare Advantage plans.

Here are some interesting features about all this activity:
  • This is one of the rare times that Republicans were caught between two powerful special interests in healthcare who are both typically strong Republican supporters. The doctors and the AMA ended up on the winning side and the large private health insurers on the losing side
  • Many Republicans switched votes only after doctor groups targeted them in effective ad campaigns in their home voting areas, specifically publicising their opposition up to that point on the bill
  • Many Republicans ignored directives from their own party whips and Congress leadership, and of course broke from Bush on this as well. Facing difficult re-elections can be effective in prodding lawmakers to do the right thing
  • By tying the Medicare fee protection for doctors with doing away with subsidies for insurers, the Democrats (and some like-minded Republicans) have won a high stakes game of chicken

The logic behind encouraging private insurers to run any Medicare type plans is that they will do so more efficiently and cheaply than a more wasteful government. But the private plans have been costing the government 13% to 17% more than what the government incurs in running its own plans. So what's the justification for these private plans with their extra subsidies? So far I've heard nothing beyond empty catch phrases like "more patient choice."

Still, the financial implications of this bill are miniscule ($20 billion over five years) compared to the $2.25 trillion US healthcare expenditure in 2007. Even for these amounts this is basically a transfer of wealth between industry players that doesn't of itself lower total costs. Hopefully it is a prelude to other reforms that bring US health costs somewhat in line with those in the rest of the developed world.

Sunday, June 8, 2008

Is Medical Travel Good For The Host Country?

There was this New York Times article of June 1, 2008 titled "Royal Care For Some Of India's Patients, Neglect For Others." It describes the state of the art care in opulent surroundings received by a US medical tourist getting his heart valve replaced in Wockhardt Hospital, Bangalore. This is contrasted with the miserable plight of India's poor patients in government-run hospitals like the Bowring Hospital on the other side of Bangalore that lack the most basic equipment.

The article doesn't explicitly say this, but I hear concerns about medical tourists soaking up India's scarce medical resources that should instead serve its own people. Such sentiments are voiced by a small minority of populists and parochial elements in India. Interestingly I saw several such views expressed by US providers in forums discussing our own WSJ OpEd of May 27th. It reminds me a bit of the protectionists who seek to block cheaper foreign goods from entering the US because of their professed concern for the poor, exploited workers abroad.

But most Indian planners and leaders want to promote medical tourism. They believe that medical tourism is a win-win, to use a cliche, with benefits going beyond foreign exchange or trade gains, to actually help Indian patients. I fully subscribe to this opinion.

The elite private Indian hospitals we've talked with say that richer patients (including medical tourists) heavily cross-subsidise poorer ones. At a fraction of US rates, what is charged by elite Indian / South Asian hospitals may seem dirt-cheap by US standards. But payments by patients staying in luxury or deluxe rooms are far higher than for patients in wards or shared rooms in the same hospital. The higher revenues allow not just for cross-subsidy but also to enable the hospitals to acquire the advanced facilities and equipment, and to attract the most qualified doctors.

The private hospital "general ward" rates in turn are much higher than the cost of care in government hospitals. The increased revenues and demand should mobilize resources on the supply side. Luxury hospitals are sprouting all over the major cities. The one aspect that central planners must address is the need to vastly increase the supply of good doctors, nurses and other healthcare workers by plowing some of the revenues into expanding medical education and training. At least from their speeches and policy declarations it looks like the leaders and bureaucrats in healthcare are working on this issue.

So Western medical tourists are good for India and should avail of the facilities there with a clear conscience. Also remember that presently they make up a very small sliver of the total clientele of even the top Indian hospitals with JCI accreditation.

Tuesday, May 27, 2008

Our OpEd in WSJ - Free Trade In Health Care

Today (May 27, 2008) The Wall Street Journal carried the Opinion Editorial (OpEd) jointly written by Professor Jagdish Bhagwati and me on p. A19 titled, "We Need Free Trade in Health Care."

Our original version was about 1000 words (shortened to 700 words in the WSJ) and is posted on our Global HealthNet website. For those who do not subscribe to the WSJ, the published version is reproduced below:

We Need Free Trade in Health Care

May 27, 2008; Page A19

Health-care reform is a major election issue. Yet while Democrats Hillary Clinton and Barack Obama offer comprehensive plans, important gaps remain. Neither plan addresses the need for more doctors, a problem that Gov. Mitt Romney ran into when he introduced comprehensive medical coverage in Massachusetts in 2006.

The other problem is the cost, an issue that earlier this year killed Gov. Arnold Schwarzenegger's ambitious attempt at reform in California. No presidential candidate can afford to ignore the potential of international trade in medical services to address these issues. Consider the four modes of service transactions distinguished by the WTO's 1995 General Agreement on Trade in Services.

Mode 1 refers to "arm's length" services that are typically found online: The provider and the user of services do not have to be in physical proximity. Mode 2 relates to patients going to doctors elsewhere. Mode 3 refers mainly to creating and staffing hospitals in other countries. Mode 4 encompasses doctors and other medical personnel going to where the patients are. All modes promise varying, and substantial, cost savings.

Arm's-length transactions can save a significant fraction of administrative expenditures (estimated by experts at $500 billion annually) by shifting claims processing and customer service offshore. Nearly half of such savings are already in hand. Foreign doctors providing telemedicine offer yet unrealized savings. We estimate that the savings in health-care costs could easily reach $70 billion-$75 billion.

Mode 2, where U.S. patients go to foreign medical facilities, was considered an exotic idea 15 years ago. Now this is a reality known as "medical tourism." Today, many foreign hospitals and physicians are offering world-class services at a fraction of the U.S. prices. Costly procedures with short convalescence periods, which today include heart and joint replacement surgeries, are candidates for such treatment abroad. By our estimates, 30 such procedures, costing about $220 billion in 2005, could have been "exported."

Mode 3, with hospitals established abroad, will primarily offer our doctors and hospitals considerable opportunity to earn abroad. Of course, the establishment of foreign-owned medical facilities in the U.S. is also possible, and could lead to price reductions by offering competition to the U.S. medical industry.

Mode 4 concerns doctors and other medical providers going where the patients are. It offers substantial cost savings, since the earnings of foreign doctors are typically lower than those of comparable suppliers in the U.S.

But the importation of doctors is even more critical in meeting supply needs than in providing lower costs. According to the 2005 Census, the U.S. had an estimated availability of 2.4 doctors per 1,000 population (the number was 3.3 in leading developed countries tracked by the OECD).
Comprehensive coverage of the over 45 million uninsured today will require that they can access doctors and related medical personnel. An IOU that cannot be cashed in is worthless.

Massachusetts ran into this problem: Few doctors wanted (or were able, given widespread shortages in many specialties) to treat many of the patients qualifying under the program. The solution lies in allowing imports of medical personnel tied into tending to the newly insured.

This is what the Great Society program did in the 1960s, with imports of doctors whose visas tied them, for specific periods, to serving remote, rural areas. U.S.-trained physicians practicing for a specified period in an "underserved" area were not required to return home.

It is time to expand such programs – for instance, by making physicians trained at accredited foreign institutions eligible for such entry into the U.S. But in order to do this, both Democratic candidates will first need to abandon their party's antipathy to foreign trade.

Mr. Bhagwati is a professor at Columbia University and senior fellow at the Council on Foreign Relations. Mr. Madan is the CEO of Global HealthNet.

Monday, May 5, 2008

Sizing The Causes Of High US Health Costs

I've just updated my work on quantifying the causes (or villains if you will) behind soaring US healthcare costs. This is now posted on our globalhealthnet website.

The article answers a very obvious question that isn't addressed elsewhere: What are all the reasons for US healthcare costs to be over twice those in other first world economies, and what is the precise contribution (in dollars per capita) of each of these factors? Identifying and then understanding the relative magnitude of the problems goes to the heart of the political and policy debates in this election season before proposing any solutions.

In other words if the OECD median healthcare cost is $2,922 per capita in 2005 and the corresponding US figure is a whopping $6,401, what contributes (and how much) to this difference? I list, quantify and briefly discuss the seven factors responsible for this difference. Interestingly, the two smallest factors are the ones that US healthcare apologists play up the most: malpractice insurance premiums that add 1.5% and "more" care and services that add 3.5% to the total bill.

The other five factors adding to US costs in order of their percent contribution are medical resource waste (15%), administrative waste (14%), defensive medicine (9%), inflated physician salaries because of artificially induced scarcity (6%) and higher drug prices (5%).

You'd have expected this topic to have been widely addressed and talked about by the healthcare industry pundits, experts, academics and researchers. Publications like Health Affairs or the New England Journal of Medicine should have been full of peer-reviewed articles on this. But there may be a good reason that hasn't happened.

The industry players collectively benefit enormously from the high US health expenditures. So long as they point fingers at one another without precise quantification it is easier to escape the spotlight and let the existing system continue. A publication like this will offend all players, and anyone dependent on the industry risks losing a career, tenure, research grants, consulting assignments and speaking engagements. People also tend to be protective of their own interest groups. For example in my July 16, 2007 post I had described the distorted reporting by Dr. Sanjay Gupta while critiquing "Sicko" even as he posed as an objective journalist.

Even from my perspective, high US health costs and a dysfunctional system with lots of uninsured people helps boost medical tourism. So why did I write this article? I'd like to think it's a matter of conscience or the satisfaction of working towards a better system for consumers. A more cynical view by others can be that I don't really expect much change from my good-guy efforts. It's like electric utility companies that make their money selling power, and yet send those mailings urging us to conserve energy and offer tips on how to do so.

Tuesday, April 15, 2008

Swallowing Medical Tourism Claims

It intrigues me how easily respected publications swallow and reproduce false and misleading claims by self-promoters. I belatedly came acrosss this story in the March 24th issue of BusinessWeek titled "Outsourcing The Patients."

It's about medical tourism taking off, and US health insurers like the Blue Cross & Blue Shield of South Caroline letting US patients get treatment in good foreign hospitals. The comparative cost data presented in the accompanying table caught my eye as it looked so wrong. The cost of a standard heart bypass procedure in the US, Singapore, Thailand and India is shown as $130,000, $18,000, $11,000 and $10,000 respectively. Though figures vary by source my best "apples-to-apples" estimates for these countries would be $70,000, $30,000, $18,000 and $10,000 respectively.

The $130,000 for US based procedures appears to be based on the inflated "list" prices that are billed by U.S. hospitals to the hapless uninsured walk-ins. But these cases are less than 8% of the total, and even among these the providers on average realize only a fraction of the charges. Instead, the providers are typically paid "negotiated" rates that are about half the list prices. The rates listed for Asian countries should be for comparable JCI accredited "five star" hospitals. Singapore's own hospital administrators say that their prices are about half of US prices and several other sources including medical tour operators confirm this. The same sources can confirm Thailand hospital prices that are about half to two-thirds of Singapore prices (or one and a half to two times the Indian prices.)

Why did BusinessWeek so understate Singapore and Thai prices? Their listed source is the Thai Public Health Ministry. This ministry doesn't appear to have the data on their website, and gave numbers to make Thai hospitals look good compared to their Indian counterparts. BusinessWeek could have easily caught the errors by using other sources to check this information.

However, this misinformation pales in comparison to the claims by Thailand's Bumrungrad Hospital mentioned in my earlier post of August 17, 2007. Another BusinessWeek article of March 17, '08 quotes the American CEO of Thailand's Bumrungrad Hospital as saying that 65,000 Americans were treated there in 2007. A back of the envelope calculation exposes the absurdity of this claim. Bumrungrad's total revenue in 2007 according to their financial disclosures was 9.4 billion Baht, or $299M (not the $555M reported in the article.) Now assuming an average payment of $8,000 per American patient, the revenue from 65,000 Americans alone would be $520M, not counting all the other million or so patients. I'll be surprised if more than 2,000 US patients visited Bumrungrad in 2007, so they're exaggerating by a factor of about 30 or 3000%.

Given this, I worry about how much faith we can place in the integrity of such medical institutions, or their quality of treatment. The chicanery of one or two prominent hospitals can give a bad name to medical tourism as a whole. But here I'm focusing more on the accuracy of reporting and maintaining journalistic standards. BusinessWeek is not alone in this. The New York Times and The Pittsburgh Post-Gazette were taken in by similarly outrageous claims by Bumrungrad in 2006. I noticed another contradictory statement in the BusinessWeek March 17th article - that said "The big problem, though, is that Bumrungrad is now too popular... [with a low] 70% occupancy rate.." Huh?

I'm aware of the tremendous pressures on the harried and underpaid staff of these publications to rush stories to the press. But they owe their trusting readers a little fact-checking and verification, while saving themselves from serious embarrassment in the bargain.

Thursday, April 3, 2008

Of Thermometers And Ailing Globalization

I don't want to overblow it. But shopping for the most basic item of home health can hold lessons about broader management practices. I've been unable to buy a reliable digital thermometer in the US. I finally obtained it from India. Here's how it happened.

Last month Anita and I came down with the flu. Our old glass and mercury thermometer took too long for an accurate read of temperatures. A couple of good digital thermometers we had bought more recently (one in the US in 2000 and another in India in 2004) had been passed on to our children.

So I went to a CVS pharmacy to buy another digital thermometer. There were several types on display - store brands as well as the better known Vicks brand. They varied essentially in the time they took to record temperatures, ranging from 5 seconds to a minute. They all claimed on their packaging to be accurate within 0.2 degrees F in accordance with federal standards.

The problem is, they weren't. The CVS brand I first bought for $6 was off by over 2.5 degrees when compared with our reliable mercury thermometer. Moreover, readings varied widely on successive tries. Then I exchanged it for the Vicks brand for $14. Same story. I then visited Rite Aid pharmacy and bought another which was also hopelessly inaccurate. Finally I talked to the pharmacists at both Rite Aid and CVS about this. The Rite Aid pharmacist said he had received many complaints about all the types and brands of thermometers that they carried, and couldn't recommend any one of them. All were made in China. It was the same thing (and the same Vicks brand) at Walgreens. The reliable "Made in USA" digital thermometers I had bought seven years ago were as extinct as the mammoth.

The CVS pharmacist said the only ones likely to work were the old glass types filled with liquid (a mercury substitute, since mercury thermometers are now banned here for safety reasons.) I finally bought a glass and liquid type which thankfully works fine though it requires 3 minutes to record temperatures. The brand name is Geratherm and it was the only one not made in China, but in Germany instead.

As we still preferred a faster-reading digital thermometer, Anita called her brother Prakash who happened to be visiting India at that time. He easily picked up a good digital thermometer made in Taiwan from a local Indian drugstore and brought it back to USA for us.

At present, corruption and the "anything goes" culture in China makes it easier to get away with poor quality manufacturing and adulteration of goods. Does this mean goods coming out of China are necessarily inferior? Not at all. There are articles about Japanese companies that flew their quality experts and manufacturing teams into China and thus ensured top quality. The best laptop in the world at present is the Chinese made Lenovo ThinkPad X300, according to BusinessWeek (March 10, '08).

The problem lies in the attitude and priorities of the US managers who procure from China. Instead of stressing high quality at an acceptable price they seek the lowest price for acceptable quality. And "acceptable quality" often means whatever does not get the procurer into trouble in the time he holds that position before moving on. In our digital thermometer case the outsourcing manager(s) at Vicks and the buyers for the drug store chains probably got kudos and promotions for having cut costs and boosting profits in the short term. By the time it became known that these thermometers were junk these people were probably in other positions and never held accountable.

This story repeats with countless products sold in the US by a whole range of companies. The practice flows from top managements that do not track the consequences of their executives' past decisions and reward short term performance. US CEOs are themselves driven by quarterly targets and myopic goals. This can apply to small, private companies that deliver services as well.

One such example of short term opportunism trumping long term interests is in medical tourism, an area of healthcare services of special interest to me. There are several small companies offering their advice and services to outgoing US patients. They can be strongly tempted to steer patients to hospitals and clinics based on the fees they realize, while compromising the quality of treatment. The danger extends beyond the obvious ones to their patients' wellbeing and to their reputations or legal exposure. Just a couple of well publicised mishaps can shake the confidence of medical tourists and severely damage the nascent medical tourism industry as a whole. That's a whole lot worse than a pile of junk thermometers being returned to drugstores.

Sunday, February 17, 2008

Right To Death

A Feb. 5th article by Jane Brody in the New York Times articulates a lot of my feelings about exiting life gracefully. I admire people with a strong will to live and am all for giving them the opportunity and means to prolong their lives as much as possible.

At the same time there are many people who haved lived full lives and don't want to end up with a miserable, lingering existence when they're too old, sick and incapacitated. Add to this group those who are terminally ill, know for certain that drastic and highly painful treatments will only get them a few months, and would rather pass away on their own terms. If or when I'm in such a situation I'd solidly prefer this option.

I'd go further in case I developed a condition that gives me only a few more months to live. I'd then prefer an immediate exit if it can save multiple other lives, e.g., through donation of organs that are still usable, instead of waiting till these are also ravaged by time and further treatment. Laws should be enacted that would allow me to do this.

I thought well of Dr. Kevorkian for pushing for legalization of assisted suicide under the right circumstances. Oregon and countries like The Netherlands, Belgium and Switzerland have taken welcome steps in this direction and I hope the rest of the world follows suit. While economics should not be a key factor in this debate a study I saw found that 28% of all US healthcare spending is on people in their last year of life.

Any laws allowing assisted suicide or euthanasia should have strong safeguards of course. What we would certainly not want is any person feeling pressured (even through silent cues and non verbal behavior) to end their lives to avoid being a burden on their family or others. I believe Oregon addressed this, and any further improvements can be carefully considered.

There's a related issue of the dilemma faced by the families of people who can no longer make their own decisions, and haven't made living wills covering their circumstances. A relative of mine faced this very difficult decision and felt torn before and after making it. I say to that person that you did the right thing, and this took a lot more bravery and fortitude than shirking responsibility.

Finally, getting to the brighter issue of continued living when it needs long term and/or assisted care, it's worth considering care overseas. It's a variant of medical tourism that is just beginning to be looked at. It can greatly ease the financial and physical burden of caring for Americans unable to look after themselves. Further, it can improve their quality of life thanks to an abundance of good, inexpensive help available in the right places. I just finished a little study for one such facility in India. I'm merely mentioning this idea here as it merits detailed discussion separately.

Tuesday, January 22, 2008

Choosing The Right Medical Tourism Company

I won't go here into whether US medical tourists should deal directly with foreign doctors / hospitals or use one of the several medical tourism companies that offer to help facilitate the process. That can be the subject of a separate post. The latter option certainly makes things easier for most people.

I'll proceed from the point where you or your loved one are (a) exploring medical tourism as an option for your condition and circumstances, and (b) planning to use one of the "free" medical tourism operators in case you go abroad.

Since US insurers have been tardy about offering medical tourism solutions with the right incentives, I'll also assume you're individuals who are planning this on your own, and paying mainly or entirely out of pocket.

You'll likely know about these operators either through medical tourism accounts in the media, or typing something like "medical tourism" in a search engine like Google and seeing the sponsored and unsponsored links leading up to these operators' websites. You'll probably see about half a dozen to about a dozen options. You may like to study all the websites, and perhaps also Google the names of the medical tourism companies to see if any relevant stories or references about them come up.

I know some "good" medical tourism companies but none of them is anywhere near ideal in my view. So I won't name any companies, and leave you to choose one based on your own judgement. But listed below are some of the key factors that should help your decision:
  • Credentials of the management team: Does the company list its management and their bios? What is their background and experience, and how relevant is it to healthcare and the services they are offering? Do they have certified doctors and/or nurses to help or advise you?
  • Who are the foreign partner doctors and hospitals? The choice of the doctor for your specific procedure, followed by choice of the hospital are the two most important decisions, and it's a huge plus to have a company that allows you to see and evaluate both. Some people wonder how important is JCI accreditation for a hospital. This accreditation at least establishes a certain standard and demonstrates the hospital's interest in serving quality conscious medical tourists. It does not guarantee that the hospital is world class, or that there aren't better hospitals around. Still, given that over 100 hospitals worldwide are now JCI accredited and the list is growing, you are likely better off limiting yourself to JCI accredited hospitals, particularly for major surgeries
  • Access to live operators and relevant help: Most companies will have a phone contact number (often toll free) in addition to web-based query forms or email. You should call such numbers and have your questions answered. This will also give you a feel for the company. If you are kicked into voicemail or fail to reach someone live, that's not a good sign for two reasons: (a) It is indicative of a small operation that is not sufficiently or professionally staffed and (b) You may have similar problems contacting the company in real time if you need their help once you are abroad
  • How much information is out there? In general, having a lot of good, up to date and relevant information on the website (while avoiding clutter) is indicative of professionalism, aside from being useful to the patient.
  • How "open" is the site? Some sites have stopped showing their partner doctors and hospitals, because of cases where medical tourists have used the information to bypass the company and go directly to these providers. For the same reason, some sites require prior registration before allowing greater access, so that they can collect their marketing fee from the attending hospital even if the patient subsequently bypasses them. These developments are understandable though unfortunate. A free flow of information allows for comparisons and sounder choices by patients of medical tour operators
  • Information on medical procedures and pricing: In general, it is a good sign if the company posts some typical procedure prices and descriptions on its website. Beware of bait pricing, though some operators have been forced to adopt this practice because they'll be otherwise disadvantaged by their unscrupulous competitors
  • Services offered, the infrastructure and arrangements in the foreign location: You should compare the services being offered and whether/what you're being charged for them. Services include arranging for visas, transmitting medical records, getting appointments with the foreign doctor, travel arrangements, cell phone in the foreign country, meet and greet at the airport, having a companion or local contact in the foreign location, local transportation, etc.
  • Word of mouth: This is admittedly a tough one, but great if you can manage it. Talking to former customers/patients who used the company can be very useful so long as the company is not cherry-picking only those who they know are very satisfied or served well. If the company can somehow let you draw upon a "random sample" that can be a lot better. By random sample I mean that they describe and list the patients in general terms (to protect privacy) that they sent in an interval of time that you specify and let you pick the patient you'd like to talk to (if the patients are willing to do so, of course)
  • Testimonials: These can suffer from the selection bias I talk about above. That is, the company lists opinions of only the most satisfied customers and you've no idea about any horror stories. Still, some companies carry a very large number of detailed testimonials and video discussions that can be educative
  • News reports and media stories: This may not be a huge factor because the media can also be fooled by hype as in Bumrungrad's case (this is a hospital, not a medical tourism company.) But a lot of favorable media coverage of a company and the company's history can be reassuring. Plus, such a company will have a reputation to protect. Don't confine yourself to the stories listed on the companies' own websites - they will obviously exclude negative material. You should use search engines like Google and look through the "unsponsored" links to get more information. This is likely to be helpful even though companies can maneuver some high listings through SOE (search optimization engine) techniques

Most of these companies are paid a fixed percent of the package cost by the hospitals as marketing fees or commission. So they stand to earn more if you go to a more expensive hospital. This is just something you should be aware of, though they may advocate a more expensive option for bona fide health reasons and for your own well being.

In closing a little research and comparison shopping can very worthwhile. Good luck!

Wednesday, January 9, 2008

Nice`Little Surprise In Hillary's Health Plan

You may miss it unless you look closely. And I'm not surprised Hillary doesn't talk about it as it can turn off an important Democratic constituency. I'm talking about that last little point tucked away in Hillary Clinton's 7 step strategy for controlling healthcare costs. This point relates to putting in place "common-sense" medical malpractice reforms.

Although her plan does not elaborate very much on this, it is remarkable that a Democratic candidate had put this on the table in early Primaries season, in May 2007. To my knowledge there is nothing equivalent put forth by Obama or former trial lawyer John Edwards. The American Bar Association and its subset of trial lawyers wield disproportionate influence on Democratic hopefuls. Anything smacking of malpractice caps, however necessary, has been the exclusive domain of Republicans, even if it is vital to controlling runaway US healthcare costs. This may signal Hillary's determination to address healthcare reforms in a sincere and non-partisan manner.

Of course, medical malpractice insurance or payouts are a miniscule part of healthcare expenses - less than 2%. The most damage is done because of the modifications induced in the behavior of providers because of this fear of expensive lawsuits. This includes both stultifying procedures and bureaucracy meant to reduce legal exposure that creates inefficiencies adding about 10% to treatment expenses, plus another 9% because of unnecessary tests and treatments through so-called defensive medicine. Malpractice reforms will not eliminate these wastages by any means, but can considerably reduce them, and so should be part of any bipartisan healthcare reforms.

How this all plays out if a Democrat is elected President remains to be seen but I see the very mention of malpractice reforms in Hillary's plan as an encouraging first step.

Thursday, January 3, 2008

Some Remarkable Comparisons

In my just concluded trip to India I saw healthcare beyond the medical tourism destinations in JCI accredited hospitals. The elite hospitals in cities like Delhi, Mumbai, Chennai and Bangalore deliver US quality healthcare at low prices. But what of other places?

I received some answers in respect of Pune where Anita's Daddy and Mummy (my in-laws) live. Pune (population 4.5 million) is a large city, but a fourth of the size of Mumbai which is 220 Km (140 miles) away. Moreover, in terms of business activity and infrastructure, including in healthcare it is a relative backwater.

Still, Mummy needed an eye cataract surgery and we restricted ourselves to local options. There were several challenges. We wanted the pre-operative tests and prep, the main surgery and the next day follow up visit to be completed while Anita and I were there. Daddy and Mummy have lived for decades in their second floor walk-up apartment. They haven't wanted to move, and as Mummy can now hardly walk leave alone climb stairs, she hadn't been outside of her apartment for two years.

Happily, everything has worked out well so far. One of Pune's leading eye surgeons, Swiss-trained Dr. Rajeev Raut had performed cataract surgery on Mummy's left eye eight years earlier. On December 27th he operated on Mummy's other eye and her prognosis is very good. She has been taken to Dr. Raut's clinic three times by stretcher and ambulance and has three subsequent follow up visits to go. Here are some remarkable aspects of our experience:

1. Accessibility. In the US it would have taken a week just to get an appointment to discuss our case with a doctor, and over a month to schedule a surgery. In the busy Raut clinic I just walked in and explained my problem. The helpful counter ladies instantly pulled up the history of her prior surgery and asked me to wait. In ten minutes I was taken to Dr. Bhargava, the coordinating physician who spent the next half hour with me. He outlined the pre-surgery tests needed, and arranged the urgent scheduling needed for the surgery and two days of crucial follow up care to be accomplished in the seven days that Anita and I were in Pune. He also had the staff give me the contact information for the clinical labs and ambulance services we needed to use. Within two hours I headed back home after (a) securing the schedule at Raut Clinic, (b) arranging for a clinical diagnostic lab to have their health technician come home the following morning to collect pathology samples from Mummy and deliver the test report that same evening, and (c) arranging for an ambulance with helpers to take Mummy by stretcher from her apartment to the vehicle and then on to Dr. Raut's clinic 3 miles away and back.

2. Competence and care. The five doctors at the clinic involved in Mummy's care (Dr. Rout the eye surgeon, Dr. Bhargava, ophthalmologist, anesthesiologist and general care physician) were all efficient, responsive and caring. Dr. Raut enjoys a great reputation in Pune and looked to be up with the latest techniques. I gathered that on average he performs five or more surgeries in a day starting at 7am and then sees numerous (I'm guessing about 30) other patients. Yet he spent the time needed to discuss Mummy's case with us during the preliminary and post surgery visits. The way he cupped Mummy's face and stroked her hair the first time after examining her visibly soothed and reassured her. The rest of the staff was polite, helpful and efficient as well. The halls in the clinic had a lot of examination stations and equipment manned by dedicated technicians. The whole process had a smooth, streamlined feel to it, like I've seen in good US physician offices, though the patient throughput here was higher and the spaces packed more tightly.

3. Ambulance and ancillary services. Americans would laugh at the ambulance vehicle that we used. It's a converted Maruti Omni minivan ("microvan" is a more appropriate term) powered by a 0.8 liter 3 cylinder engine and has a wheelbase smaller than a Cooper Mini . Still, it holds the patient on a 20 inch wide stretcher with docking frame and rails plus four other people including the driver, and is good for negotiating Pune's narrow, busy roads. The ambulance driver and two helpers adeptly moved Mummy between the apartment and the vehicle via the stairs, and were reliable and responsive. Once at the clinic we had plenty of help to transfer Mummy to a wheelchair in the parking lot so that she could be taken up two floors to the clinic in the tiny elevator that holds 4-5 people.

4. Cost Comparisons. This is like saving the best for last. Here are the costs we incurred as compared to estimated US prices (those too at the "negotiated rates", not the "list prices"):

-Clinical pre-operative blood and urine tests including the three home visits by the technician to collect the samples and deliver the report at the end of the day -- Rs. 500 ($13) in all. US costs without home visits would be $150-$200.

-Ambulance transportation and evacuation charges including the services of two helpers and a driver including tips -- Rs. 500 ($13) each way. US cost: $200.

-Pre-operative examinations, consultation and tests (including ECG and eye tests after dilation) at the Raut clinic -- Rs 900 ($24). US cost: $150.

-Total surgery package cost including all physician fees, intra-occular lens and 4 follow up visits -- Rs. 24,000 ($600). US costs at Medicare rates (an awfully hard number to pin down by the way, because of complicated and secretive billing systems): $3,000.

- All medications for the next few months, and medical supplies -- Rs. 1,600 ($40). US costs: $300.

In sum, we'll end up paying $900 in Pune for care that would cost $6,000 in the US. Moreover, the steps including the actual surgery and the two days of crucial follow-up care were accomplished in the 8 days Anita and I were at Pune to help Mummy and Daddy out. I'm guessing that would have been enough time in the US to get our first consultative appointment, though in fairness there are a lot of positives in the US experience that I haven't gone into.

Now we're back in the US and Mummy is progressing well in Pune with Daddy's help. Anita's cousin Rita is traveling from Mumbai to Pune to accompany Mummy on her second follow up visit to Dr. Raut (when she gets her prescription glasses) on January 7th.