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.
Sunday, June 8, 2008
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
By JAGDISH BHAGWATI and SANDIP MADAN
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.
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
By JAGDISH BHAGWATI and SANDIP MADAN
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.
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.
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.
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.
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:
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!
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