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.