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.

15 comments:

Anonymous said...

just confirm the method used there is

phaco with foldable? it think its not
As they do not give any details of
method of surgery,labels and proof
of IOL used.which is must all over the world
I think they do it by manual
method which is not accepted globally.

Sandip Madan said...

I don't know about this "phaco with foldable" but the surgeon is Swiss trained and the method they use is described as "Stitchless state of the art surgery." My mother-in-law is doing very well and to our pleasant surprise her sight in her operated eye is near-normal. We were all very worried about macular degeneration in addition to the surgical outcome which was excellent.

Anonymous said...

Since your matter is on global platform, is necessary to give exact information.about good out come of surgery more than 99% cataract suregeries have excellent
outcome even at rural level.
only stichless does not mean best method and IOL.
at present tecnis lens by AMo is best reducing glare.also oPtion of multifocal is there.
all this should have been explained to you and all detail documentation shold have been handed over to u.
Just a good experience and cheaper price do not consider thease things AND ENSURE TECHNIQUALLY BEST SURGERY
There r much more in eye surgery than u know.

moral just dont get carried away by pleasent experience,try to
unserstand tecnical points about it.i am telling so much as u seems to be related with this field.
At present a micro/phaco with ASPHERIC TECNIS lens IS the best option by international eye suregeons.If same thing is not done ,then u cant compare that pricing with what u got at mentioned clinic.
I am not saying it did not worked out(as she can see good) finer aspect of vision with many more options of lens should have been offered.
pl. ask in detail which lens was used in WRITING and method in WRITING.
I AM SURE THEY WONT.TRY

Anonymous said...

U CAN SEE ADVANTAGES OF technis foldabel on www.TECHNISIOL.COM

Sandip Madan said...

It's a busy practice and the doctors are not soliciting business. Can you share your identity and credentials? That'll help me decide whether to take up the time of the clinic, and/or invest my own for any further inquiry.

Sandip Madan said...

Btw, I did visit the website mentioned in that previous anonymous comment. It is spammy, with pop-ups. This is just to caution anyone going there...

JAY MEHTA said...

I AM AN EYE SURGEON TRAINED AT
MOORFIELDS EYE HOSPITAL,LONDON.
(HOSPITAL WHERE IOL WAS INVENTED AND IMPLANTED FIRST TIME IN WORLD)
ITS ON OLD STREET UNDERGROUNFD STATION IN LONDON.I HOPE THEASE MUCH CREDENCIALS ARE ENOUGH TO SPARE YOUR TIME.
ISSUE IS NOT OF YOUR PESONAL EVENT AS ITS ON GLOBAL PLATFORM AND YOU ARE CONSULTANT FOR MEDICAL TOURISM
HOW CAN YOU RECOMMEND YOUR CLIENTS
AN EYE SURGEON OF WHOM U DO NOT KNOW
TECHNIQUE OF OPERATION,IOL USED,CHOICES OF IOLS.
IF ONLY THE APPEARANCE OF CLINIC,GOOD TREATMENT BY DOCTOR IS ALL THAT
IMPRESSES YOU,THEN HOW CAN U BE A MEDICAL TOURISM ADVISOR?
DONT TAKE PESONALLY BUT SIT DOWN AND THINK.YOU SAID U DONTS KNOW ABOUT PHACO WITH FOLDABLE WHICH IS
ABC OF EYE SURGERY.
I AGAIN REQUEST DONT TAKE PESONALLY.

Sandip Madan said...

Ah, Dr. Mehta, I now see where you are coming from. Where do you currently practice?

Some clarifications: 1) I do not pretend to have deep medical knowledge, least of all in eye surgery. We went to Dr. Raut because he is well known in Pune, has a great reputation, AND had operated on Mummy's other eye eight years ago. 2) I recounted our experience as one example of good care available in India for reasonably well-off Indians, while comparing it to US care. 3) I am NOT recommending Dr. Raut for medical tourists since Pune is not a standard medical tourism destination. It's too far from the nearest international airport (Mumbai), and doesn't have all the amenities that Americans expect or are used to.

Besides, since cataract surgery is a relatively minor and inexpensive procedure, it's just not worth it for Americans to make the trip all the way to India for this purpose.

mehta said...

Thanks for clear reply !

appreciated!


i hope u understood my reason of comments.
:)

Sandip Madan said...

Absolutely, Dr. Mehta. And thanks for all your inputs.

Paarth Akolkar said...

hey dude,
thanks a lot for this superb article.A friend of mine recently wanted to know where he could take his grand-aunt for a cataract surgery.

I was browsing around a bit and came across your article. I asked him to go for an appointment.
The operation went through fine(I was there on the day), and I can say that nothing has changed in the clinic, everything and everybody is as helpful and up to the mark as you described. The new touch screen history concept is really cool, and we enjoyed filling in her history, without even having to wait for a doctor to talk to us.
She is seeing fine, thanks again!! We were really stumped, because my friend and I ,like you , are not from Pune, and his grand-aunt lives here with relatives, and we're the only one's she has to call on.
Furthermore, I am now regularly following your blog on U.S healthcare vs cost assessment issues, and I must say that you are really well informed.
Cheers,
Paarth Akolkar.

Sandip Madan said...

Thanks much, Paarth. I'm glad this 5 year old post helped - I'm curious as to how you came upon the post as I assumed it would be buried too deep in the blogosphere to show up in a general search.

Btw, I can see you're great people. You and your friend taking care of his grand aunt in this way is commendable.

Anonymous said...

Does Dr. Raut himself operate?

Sandip Madan said...

Yes, he does all the surgeries (cataract procedures) himself.

Shyam vyas said...

I am a senior ophthalmologist who was professor and head in govt. Medical college Rajasthan and know the worth of Dr. Rajeev Raut as best and very methodical artistic eye surgeon and has done phaco and beyond i.e. laser phaco.
Please don't carried away with which lens is good and which machine should be used. His surgery gives best correction for near and distance that too without glasses.