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.

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!

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.

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.

(S)CHIP Away At Excuses

"I'm sorry, Ma'am," said the police officer as he watched the woman getting beaten and robbed, "Helping you would be socialized law enforcement." After the robber had made off with her belongings, the cop advised her to hire Blackwater private guards for her future security needs. Though Blackwater would cost thrice as much as her taxpayer dollars he informed that she could get a 20% tax rebate under the Bush plan for Private Law Enforcement Savings Accounts.

This hypothetical scenario is not much removed from the logic being advanced by President Bush and his supporters to repeatedly torpedo the expansion of SCHIP. They mainly oppose expanding free health coverage from 6 million to 10 million poor kids because it would set us on the slippery slope of better healthcare for all. Of course they've a different name for it - socialized medicine. We already have "socialized medicine" for people above 65. It's called Medicare. Who (including Republicans) wants to do away with Medicare?

I earlier talked about SCHIP in my post of August 3rd. The Bush rhetoric against it hasn't changed, though some new angles have been added. Congress had already addressed initial objections by excluding the expansion to illegal immigrants and adults. Then after Bush's first veto they've lowered the family annual income cap for eligibility to $62,000 from $82,000. But that's apparently not enough.

On the eve of vetoing the second version of the Bill, Bush criticises the Democrats for not sending a Bill "that I can sign." His ability to sign is apparently not about merits but the imperative to keep his friends happy. Chief among these friends is the tobacco lobby since the additional funding for SCHIP is proposed to be covered by extra tobacco taxes. That's okay though there are alternatives to further milking the tobacco cow. I'd prefer SCHIP funding to come from rolling back the enormous giveaways resulting from the 2003 Prescription Drug Act. We can save more on drugs simply by allowing Medicare to negotiate drug prices. But that would widen the issues and give the Bushies additional excuses to resist SCHIP. Not wanting to be sidetracked, the Democrats wisely chose tobacco monies instead.

Also, private insurers worry about children currently insured by them being drawn away to the "free" government coverage. Some of this may happen but it doesn't change the overall benefits from a public policy perspective.

The Bushies' biggest ploy is pushing the requirement that no expansion be allowed till the states certify that 95% of the currently eligible kids have first been covered. This is a near-impossible hurdle as they well know. Moreover, an expansion of SCHIP does not reduce the opportunities for covering the poorer kids. It's like city police saying that they won't investigate any rapes or robberies until they've solved 95% of all past murders. If the Bushies were sincere in their concern about the poorer kids they'd seek simplified aplication procedures that would make it easier to cover such kids. Instead they insist on "safeguards" that make the task harder.

The Republicans' resistance to SCHIP is unpopular. I wonder whether some management gurus are being naive or deceptive in trying to spin this as simply a communications issue. Jack Welch in his BusinessWeek column of October 22, 2007 misses the mark in saying that Bush erred by not getting out in a big way to broadcast his detailed reasons for opposing SCHIP. The real reasons are that Bush wants to protect his cronies and fund contributors - hardly something that he can shout from the rooftop. The fake reasons he might give in campaigning harder against SCHIP are likely to get exposed during news analysis that would accompany such publicity.

There's a good graphic in an Oct. 17, '07 article in the New York Times (created by daughter Rubina, incidentally) that shows income limits and the number children and adults enrolled state by state. It shows one fifth of the states have a substantial number of adults included in the program. The pending SCHIP Bill will not expand adult coverage, but more importantly, note how just one state (New Jersey) has a family income limit above $62,000, at $72,275. So much for Bush publicity on how "rich" kids with family incomes of up to $82,000 will benefit from SCHIP.

As Bush is getting ready to veto a second SCHIP Bill, talks are reportedly proceeding on a third version that will be to Bush's liking. The man hath no shame. The Democrats may have little choice but to accede to this watering down in order to protect kids who are already covered, since the current legislation is about to expire. Still, it'll be a pity if any meaningful changes have to wait till Bush leaves office.

A Good White Paper On Medical Tourism

My colleague David Williams and his associates have come up with a great white paper on medical tourism from the US perspective. It has good information and analysis on several aspects, and also comes out with some notable predictions including:

• US health insurers will start to provide coverage for medical tourism in 2008. Mini-med plans and small employers -not big health plans and blue chip companies-- will lead the way.
• State governments will begin to embrace medical tourism by 2010.
• Opposition to medical tourism by US physicians will be relatively modest.
• Medical tourism won't have a major, direct impact on US health care costs, but the secondary impact will be substantial.

If you have the time and interest it is well worth reading the full paper which can be downloaded and also accessed through their www.medtripinfo.com website.

I broadly agree with the paper's expressed opinions, forecasts and predictions. They did a good job crystallizing a lot of the wisdom into those predictions. About the prospects of places attracting US medical tourists here are my views:

Because of pricing I don't think Singapore will ever be a popular destination for Americans, though it may serve a richer clientele from neighboring areas and the Middle East. My bets are on India followed by Malaysia, Thailand, and may be China and Philippines for serious procedures; and Costa Rica / other Latin American countries for the dental / cosmetic procedures, and a few major surgeries for people who don't want to travel too far.

One development is notable in the context of a weakening dollar. A lot of places like in Europe that earlier cost half as much as treatment in the US are no longer financially viable destinations for the cost conscious, so the places like India offering much cheaper treatment will attract proportionately more traffic.

France For Medical Tourists?

France is ranked No. 1 in healthcare by the World Health Organization. Thanks to "Sicko" most people know that the US is ranked No. 37. So the question on my mind during my recent trip to Paris was: can France be a good destination for medical tourists, or is it good just for the French?

The short answer is, France does not look good at least for US medical tourists. Because of its closer proximity it can still serve rich visitors from some other countries, notably the Middle East. From my informal conversations with a lot of the French people I had the same impression that is widely reported in the media - by and large the French are satisfied with their own system even if policy planners are worried about the budgetary gap.

On the last point one thing stood out: almost everyone I talked with said social security paid French healthcare was satisfactory and adequate, but not outstanding. Many said that if cost was no object then they would prefer to go to the American Hospital of Paris. This is a US managed private hospital that does NOT accept the French social security system of payment or reimbursement, and is a favorite among rich Parisians. The reason: it has very attentive staff, ultra clean and somewhat luxurious facilities, and well qualified doctors (many of them working as consultants rather than employees.) I confirmed this in my own tour of the hospital. Rebecca Alliegre who showed me around sounded disappointed when I remarked it was similar to the very good US hospitals I had seen. She said they hope it is better than that. I had actually meant it as a compliment - the top US hospitals are actually great, if hard for patients to get into or afford.

In contrast, I was told the regular French hospitals offer a more pedestrian level of care and attentiveness even if they have the required expertise and equipment. Moreover, none of the hospitals other than the American Hospital has a comprehensive website in English. So online information access to English speaking patients will be a problem, and there may be some spoken language problems for admitted patients as well. For these reasons I'd consider the American Hospital to be the best (perhaps the sole) prospect for US patients.

American Hospital has 180 - 190 beds and is a general surgery hospital. It does all sorts of procedures but none of the "standard" ones popular with medical tourists in very high volume, with the possible exception of angioplasties and corneal transplants.

An aside: I met a very impressive young cardiologist, Dr. Tarragano Francois, who performed 580 out of the 600 angioplasties at American Hospital last year (he does over a thousand in all, the rest being in other facilities.) He mentioned that in France teaching cardiologists (who can train others in angioplasty procedures) need to perform at least 600 angioplasties, and the certification threshold for practising cardiologists is 120 procedures (versus only 75 in the US.) It was also interesting hearing him talk about why he prefers using the latest Xience drug eluting stents manufactured by Abbott Labs, as compared to competing products like Taxus, Cypher and Endeavor. Xience allows better insertion and flows in branch points of arteries, and has a slower and more prolonged delivery of the drug that prevents clots. Very interesting stuff - I wish I had become a doctor.

Back on topic, right since 1956 the American Hospital of Paris is the only JCAHO accredited civilian hospital (not just JCI accredited) outside of the US. It was established way back in 1906 with 19 beds as a way to provide American style and quality care, and originally intended mainly for US expats working in Paris. It has come a way since then, and has upto date equipment, like a 64 slice CT scanner, and a PET scan to be operational next year.

So why is it not suitable for most US medical tourists? The biggest problem is prices. Thanks to a weak dollar, the prices here are about the same as the negotiated prices in US hospitals. My impressions are based on preliminary discussions. Thuy Tien Couty, the Director of Marketing was very cautious about disclosing prices, and she said the list will be available only in mid-November. Other French hospitals are somewhat cheaper, but the differential isn't dramatic, and besides they do not match the service levels of the much cheaper elite hospitals in places like India or Malaysia. Besides, India has super-specialty hospitals with 500+ beds that have deep expertise and quality credentials in almost all the major surgeries sought by medical tourists.

Still, some US patients with private insurance or sufficient means may opt for American Hospital because they would like to enjoy visiting Paris and recuperating here while receiving high quality and attentive care.