Thursday, June 11, 2009

Overseas, Truth Under The Knife

Expert opinion under the guise of objectivity can be highly persuasive. Three US doctors on June 10 wrote in The New York Times to rather subtly undermine the push towards medical tourism.

In their Op-Ed "Overseas, Under The Knife" Drs. Arnold Milstein, Mark Smith and Jerome Kassirer begin by praising medical tourism's "allure of good care at half the price." They also say "total fees at well-regarded hospitals like Apollo and Wockhardt in India are 60 percent to 90 percent lower than those of the average American hospital."

Then they change tack to slant some statistics, and play on patient fears and insecurities about medical tourism. Those in the industry should know better but the average reader will likely buy their story.

Interestingly, Nicholas Kristof has an Op-Ed of June 11 in the NYT cautioning against the scare tactics of health insurers against a public plan. It applies to many admonitions by Dr. Milstein et al. They denigrate medical travel by saying: (a) it won't save much money overall; (b) it poses risks and difficulties for patients; and (c) too little is known about quality of care and we should first set up protocols and collect extensive data before seriously considering this option.

Towards the end of the article they do suggest useful steps like Medicare prescribing uniform reporting and tracking of treatment information by US hospitals, and inviting foreign hospitals to participate. The data includes surgical outcomes, risk factors, complications rates and comparable measurements of long term success. Still, this doesn't allay my concerns about other parts of the article.

Some of their assertions I take issue with are below (in italics), along with my comments:
  • Offshore surgery cannot substantially lower health care costs. Less than 2 percent of spending by American health insurers goes to the kind of non-urgent procedures that Americans seek overseas. --- Huh? In our May 27, 2008 Op-Ed in the WSJ we had identified 30 such procedures with a spending of $220 billion in 2005. For 2006 the figure is $270 billion. This is 13% of the $2.1 trillion total healthcare spending, or almost 42% of the $649 billion spent on hospital care. Of this, the spending on just the top six "exportable" surgeries (3 in cardiac - valve, bypass and angioplasty; and 3 in ortho - hip replacement, knee replacement and spinal fusion) is $100 billion. That alone is 4.7% of the total health bill, or 15% of the hospital bill. Another way of looking at it is that medical tourism potentially offers bigger savings than the $1.2 trillion dollars over the next decade promised by the health industry groups amidst much fanfare to the Obama administration.

  • Compared with low-cost American hospitals, the offshore fees are 20 percent to 50 percent lower. --- This significantly understates the cost differential as well as the incentive to go abroad. Even compared to negotiated rates of cheap US hospitals (leave alone the atrociously high "list" prices) top Asian hospitals charge a lot less. A heart valve replacement costing over $100K in a typical US hospital may cost $50K in a cheap US hospital, but only $10K in Wockhardt or Apollo in India. For a heart bypass, the comaprable figures are $70K typically in the US, $40K in a cheap hospital, and $10K in India. That's offshore fees 75% - 80% lower, which is very different from a "mere" 20% - 50% differential.

  • Other negatives are obvious: people having surgery done halfway around the world are far from their regular doctors as well as friends and family. Consider, also, what happens if an American abroad falls victim to negligent care. Arranging transfer to another hospital may be difficult. --- If the authors insist on playing this "fear" card they should at least mention that the patient is far less likely to have an adverse outcome in a top foreign hospital than in an average US hospital. Take heart bypass: the US overall mortality rate for this is over 2%. It is only about a third of that (0.6% - 0.8%) at Apollo or Asia Heart Institute in India with similar favorable comparisons for infection rates, other complications and other procedures like hip resurfacing. Also, most of these foreign hospitals are multi-specialty with good general care, and in any case located in the largest cities like Delhi, Mumbai or Singapore with a profusion of other hospitals. So in the rare event of a transfer being needed it's likely easier done abroad than in the patients' home place. It's only a matter of time as one can't keep beating the odds, but as of now I haven't heard of a single fatality of a US medical tourist in the top hospitals in India and Singapore. For all this the authors only say "There is reason to think the quality of care at some foreign hospitals may be comparable to quality in the United States."

At least there's one positive to this article - someone (other than Prof. Bhagwati and I) is discussing medical tourism as an option. So far the Obama administration and lawmakers in Congress have been totally quiet on the subject.

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