A Surgeon’s Nightmare- The Other Side Of Medical Tourism

Guest post by Samuel Bledsoe MD

There is an element of a gamble inherent in the medical tourism industry as it currently exists.

An interesting thing happened to me at work the other day.  It was Friday afternoon, and I received a call from a primary care doctor. The phone call began with, “I’m really sorry about this, but I have a surgeon’s nightmare in my office.”

This is not a good way to begin a conversation.

He began to tell me about the patient. This particular woman had a Lap Band placed several years ago. For one reason or another, she decided that she would like this converted to a different procedure. She drove by my hospital to get to the airport, hopped on a plane and flew over hundreds of other well-qualified bariatric surgeons in order to reach a surgeon in Mexico where she had her Lap Band removed. She then returned 6 months later and had a sleeve gastrectomy. This is where things go bad.

The patient developed a leak from the staple line on her stomach after the procedure. She was taken back to the operating room for her third procedure where she was washed-out and large drains were placed. Amazingly, four days after the procedure, she was released from the hospital with the large drains still draining gastric secretions, a feeding tube in her nose, a prescription for oral antibiotics, and instructions to find a bariatric surgeon where she lived to finish taking care of her. At this point, she was stable and doing well. As one of two bariatric surgeons in the community, I was asked to consider taking care of this woman.

My answer, after much thought, was a refusal. I did review this woman’s extensive medical record and even spoke with her personally on the phone to try to give her some advice. One thing she said still rings in my ears, “I thought if I had any problems I could just come back here and someone else could take care of me.” I recommended that she return to Mexico until she was well. This, I was told, was impossible. I did ask my office to attempt to find help for this woman.  After my nurse spent most of the day on the phone, talking with almost a dozen different doctor’s offices around the state, there wasn’t a single bariatric or specialty surgeon in the entire state willing to accept her as a patient. Ultimately, the best advice we could give her was to go to the local county hospital emergency room for care.

Lest I be thought of as heartless, if this woman or any other patient were sick or in dire straights or needed quick intervention, I would have treated her to the best of my ability regardless of where her surgery was performed. All doctors would do the same. But a patient who is currently stable and safe, presents a unique dilemma.  Don’t I have the right to choose them just like they had the right to not choose me in the first place?  Am I required to treat every surgical disease that presents itself to me?  Shouldn’t I be allowed to help them find a higher level of care?

On the one hand, I do feel for this woman. She will never find a surgeon who will willingly take her on as a patient.  Before she is finished, she could rack up a serious hospital bill.  Although she was doing fine at the time of our conversation, I was extremely concerned about her health. She seemed genuinely sorry about her decision to leave the country and was certainly very nice. On the other hand, this places the accepting surgeon in an impossible position. Who is better able to take care of this woman’s complications than the original surgeon? Who do you think she will sue if she decides she can’t pay her hospital bill or she becomes disabled or she loses her job, and she discovers that the surgeon in Mexico is legally untouchable?

I admit to being a little frustrated towards the presumptuousness of this woman. Did she call and ask me or another surgeon if we would help in the event of complications? Who did she expect would manage her lifetime needs of follow-up after this procedure? If I’m not good enough to do your relatively straightforward original surgery, then why would you think that I would be good enough to manage the highly complicated post-operative care that is required?

However, my biggest complaint is with the current system of medical tourism. A foreign hospital system profits from American patients, and when there’s a complication, they ship them back quickly and dump them out at the local American ER. The foreign physician is immune from lawsuits by virtue of the fact that they are out of the country. The medical tourism company that linked the patient and doctor bears no responsibility since they are simply a mediator. The foreign hospital simply washes their hands of the mess that they’ve created. It’s the local doctor, the local hospital, the local medical establishment, and the local economy that pays the high price.  And most unforgivable, the patient may pay the highest price of all. Excuse me for saying, but there has to be a better solution.

Medical tourism is a newly coined term for a very old practice.  In 430 B.C, the Temple of Asclepius was built in Epidaurus, Greece. This temple was a healing shrine where the sick and infirm would travel from all over the world to spend the night in this temple. During their sleep, the cure for their ailment would be revealed in dreams. The following day the dream would be interpreted by priests who would then implement the cure. The original Hippocratic Oath contained this invocation, “I swear by Apollo the Physician and by Asclepius… .”

The Greeks weren’t the only ancient people catering to medical tourists.  For thousands of years, pilgrims would travel to Jerusalem to the Pool of Siloam for its healing powers. The Bible notes in John 9 that Jesus used this pool as part of the healing of a man blind from birth.

Even today, there are spas, resorts, and retreats the world over that cater to the sick. In my home state of Arkansas, the city of Hot Springs has been attracting the sick and injured for centuries. Native Americans and frontiersmen would travel there for the medicinal properties found in the superheated baths. Today, thousands of people travel there every year to seek the same healing.

Many nations around the world cater to the American medical tourist. It is estimated that medical tourism siphoned around $15-20 billion dollars from the US economy in 2011 alone. Hundreds of thousands of patients will leave America in order to have their care provided to them. This trend is expected to grow between 15-20% in the foreseeable future. There are a hundreds hospitals scattered at locations ranging from Brazil to Mexico to Thailand to India that have tried to establish themselves as the “go-to” location for medical tourists.

Currently, there is an impressive list of procedures from a wide array of specialties that are offered at institutions that cater to the medical tourist. One such facility, advertises care in the fields of dentistry, orthopedics, ENT, cosmetic surgery, bariatric surgery, cardiac surgery, spine surgery, ophthalmology, oncology and fertility. This only represents a partial list of what is available.  If it’s an elective procedure and profitable, it is probably offered somewhere.

In response to a growing trend in medical tourism in bariatric surgery, the American Society for Metabolic & Bariatric Surgery (ASMBS) published a position statement on global bariatric healthcare. One of their primary concerns is a concern that is shared by many- appropriate continuity of care. This concern is highlighted by the following statement: “extensive travel to undergo bariatric surgery should be discouraged unless appropriate follow-up and continuity of care are arranged and transfer of medical information is adequate.”

Certain procedures, such as bariatric surgery, are unique in the fact that they require long-term follow-up. Also, the likelihood of short-term and long-term complications are significantly diminished with appropriate follow-up. Because of this, the ethics of medical tourism for bariatric surgery has been called into question. (http://www.ncbi.nlm.nih.gov/pubmed/20346442)  

To say it differently, having a colonoscopy or your teeth filled in India is one thing,  To have your hip replaced or your heart bypassed is a different thing altogether.

I would propose three simple solutions to this to improve the current system. First, protect the innocent.  By that I mean, the American physicians and hospital systems who get involved in complications resulting from medical tourism should have immunity from lawsuits. If you CHOOSE to leave the country for elective medical care, you should forfeit your right to unlimited medical compensation from an American physician who is simply trying to fix what someone else broke. This choice involved in medical tourism is in stark contrast to someone who becomes ill or injured overseas and has to have emergency medical care. This would be similar to Good Samaritan Laws found in many states. Second, a system accrediting hospitals and facilities overseas should be further developed. Joint Commission International http://www.jointcommissioninternational.org/About-JCI/ is one such system that has standardized and defined what constitutes adequate medical care and monitors facilities for compliance with these standards. It is the oldest such commission with 450 facilities in over 50 countries. Patients should insist that the hospital where the procedure is going to be performed be accredited by JCI or an equivalent.  Third, patients should be extremely proactive.  They should obtain or confirm insurance coverage in case of complications. They should thoroughly vet both the hospital and the surgeon. They should also ensure that there is a plan in place for adequate follow-up prior to the procedure being performed. They should also obtain copies of all medical records for their physician in their home town.

Don’t get me wrong, I am an Adam Smith capitalist to my core. If a patient believes that they can get better care or cheaper equivalent care in a foreign country, I certainly believe that they have the right to do so. But the patient, the foreign physician, and the foreign hospital system should accept the responsibility for their collective exercise of freedom and enterprise. Complications should be treated to a logical endpoint, and they should be truly stable for transfer back to their local community.  There is an element of a gamble inherent in the medical tourism industry as it currently exists. I do not believe that when the gamble doesn’t pay off, my colleagues, my hospital, my community, and I should be the only ones forced to face the repercussions of someone else’s decisions.

About: Dr. Samuel Bledsoe is a General & Bariatric Surgeon in Alexandria, LA.  He is founder of Bariatric Fuel, a company that manufactures vitamins for patients who have had a surgical weight loss procedure. You can follow his blog at www.bariatricfreedom.com.

Submit a guest post and get the word out. 

Speaking of Polar Bears...

Last week at our Expedition Medicine National Conference in Washington, DC, a member of the audience came up to me after one of my talks.  Turns out this guy has a lot of experience working in remote places, and he told me a story about a colleague who was working in northern Canada and was surprised by a polar bear one morning.  Someone snapped a couple of photos of the incident, and this guy said he'd be happy to send them to me.

Needless to say, I was impressed by the photos...

In case you're wondering, the bear didn't actually catch the guy in the photos, but he sure raised his heart rate a bit.

If looking at these photos causes you to long for the frozen tundra and the bears of that region, take heart!  Our ExpedMed Polar Bear CME Adventure still has a couple of spots left.  You have the opportunity to visit the famed bears of Churchill, Canada and earn CME along the way.  The dates are October 16-20, 2011.  Below is a video created by our partners at Frontiers North Adventures...come along with us to visit the polar bears next month (if you dare).

Careconnectix.com -The New Face Of Medical Travel

Another barrier falls.

Despite the growth of domestic and global medical travel, patients leaving home for care, there are still major blocks to widespread adoption and penetration by patients and doctors. One is the communications firewall that exists. That's why we've created a free, global healthcare social networking site at www.careconnectix.com

By registering on Careconnectix, doctors can now exchange information about their countries , their credentials and specialty interests and other pricing and quality information patients need to make a reasoned healthcare purchasing decision base on value. Patients, on the other hand, can exchange medical travel experiences, rate their providers and share stories about they found quality care at an affordable price around the world.

If you are interested in being part of this growing international conversation, please join us at www.careconnectix.com, the new face of global care.

Looking For A New Opportunity?

Build a chain of Surgitels

Jackie G, a 23 y/o investment banker and avid tennis player, has arrived at the Meyers Palo Alto Surgitel following her arthroscopic shoulder surgery in a facility across the street from the hotel. Jackie lives in Denver, but came to Palo Alto because of the reputation of her surgeon, Dr. Meyers, who charged a lot less than her Denver based orthopedist. MedVoy has recommended she spend the first postoperative night at  the Meyers Surgitel Suite because of its reputation for catering to patients needing accommodations following discharge from a medical facility or needing a place to stay while getting outpatient treatment. Jackie is accompanied by her girl-friend, Sara, who will be watching over her.

Fortunately, everything went smoothly with Jackie’s operation and she was discharged from the Palo Alto Surgicenter at about 3Pm that afternoon. A hotel van takes Jackie and Sara from the Surgicenter to the Meyers Surgitel. They arrive via a private entrance with a wheelchair ramp and are met by a hotel greeter who wheels Jackie in her wheelchair to her room. Jackie and Sara have been preregistered. The room is on the ground floor with spectacular, soothing views , just right for a patient who needs rest and relaxation. The room looks like no room she has stayed in before…part hospital, part hotel. All the surfaces are antibacterial and the bedroom and bathroom have guard rails, walk-in tub and antibacterial soap to clean her wounds. The sink in the bathroom has fixtures that allow her to turn on the water with her elbows, an advantage for someone who arm is in a sling. Her friend, Sara, is staying next door and can enter through a common door. There is a small kitchen so Sara can make Jackie a bowl of oatmeal for breakfast.  The room service menu accommodates her special post op needs as does part of the menu in the hotel restaurant. An inconspicuous storage locker has medical supplies and wound dressings for medical professionals who might come to the room to visit her before she leaves for home. Her postoperative pain medicine has been delivered to her room, thanks to an arrangement made with a local pharmacy chain. She attaches her cooling shoulder apparatus.  A computer monitor allows her to communicate with her doctor and the doctor’s staff as well as her children back home. It also asks her to review a video of postop instructions before she leaves and confirms that she has done so.

During the night, Jackie is awakened with pain in her shoulder. She calls the medical concierge who has the contact information for the orthopedist taking call for Dr. Meyers. Within minutes, she gets a call and is reassured that this is a normal event following her surgery. Soothed by the presence of her Shetland sheepdog, Charlotte, sleeping next to her, she has an uneventful night.

After breakfast on the deck of her room, Jackie and Sara check out online, the bellhop takes their bags and they leave through a private exit to a waiting vehicle that will take both Sara and Jackie to her surgeon for a postop check (if she can’t come to her room) and then to a relaxing three day recuperation at a local spa arranged by MedVoy as part of her medical travel experience. They even allow pets. Much to her surprise, a few months after returning home, Jackie receives a check from her health insurance company as a reward for helping them keep down medical costs. Jackie bought a new tennis racket.

Outsourcing Healthcare

If you didn't like the idea of sending automobile manufacturing jobs to China, you're really going to hate sending healthcare jobs to Mexico.

A recent report from the Economic Policy Institute says American companies have created 1.4 M jobs overseas this year, compared with fewer than 1M in the US. Those overseas jobs would have lowered the unemployment rate to 8.9%. This, in part, explains why corporate profits are rising, the stock market is at a 2 year high, but the US unemployment rate  stubbornly approaches 10%.

The same is happening to healthcare jobs. With the global demand for quality care mirroring the rise of the middle class in emerging nations, foreign medical doctors and nurses decide to stay in China, India or Brazil. I call it pre-sourcing. Why come to the US only to find out that you had a better opportunity at home? What's more, despite a predicted manpower shortage , places like NYC are making it harder for 3rd and 4th year students at foreign medical schools to do clinical rotations in their hospitals. Telemedicine and medical travel, growing to a 1B industry by 2012, is also leveling the playing field and enticing US doctors to go overseas to practice either full time or in locums placements. Exploding expatriot retirement communties in Mexico, Costa Rica, Panama and the Caribbean are singing an irresistable siren's song attracting medical talent to those balmy shores to care for local patients and aging Americans who want care closer to their new homes.

And, it is not just doctors and nurses going abroad. Demerol dollars are following them. Take, for example, the idea being floated that Medicare pay for cheaper, similar quality care outside of the US for retired Americans...at a price that's 50% less. If that idea doesn't get your blood boiling, how about allowing Medicaid patients the option of choosing less expensive care in Latin America or Asia, in their native language?

The economics of medicine is fundamentally no different in one part of the world than in another. Money and people flow to where they are treated best. Companies hire people and build plants where the demand is the highest and the profits most attractive.

Did you ask for Rosetta Stone software for Christmas?

The 5 Top Needs For Medical Travel To Succeed

5 things will need to happen before medical travel gains enough traction to be a real player in healthcare.

Despite the research reports, eco-devo white papers, industry analyses and industry marketing hype, medical travel/medical tourism is still an early stage industry looking for the right formula for success.

In my view, five things will need to happen before medical tourism and global healthcare referrals get real traction: 1) the creation of a sustainable business model, 2) global healthcare IT connectivity and integration, 3) a physician generated global healthcare referral network, 4) a global regulatory, legal and socioeconomic ecosystem, and 5) patient awareness and acceptance.

The creation of a sustainable business model

Industry players including payors, providers, partners and facilitators are still looking for the the most successful way to make a profit and scale the business. With an eye towards what happened when Expedia disrupted the travel agency business, participants understand that margins for travel arrangement services are thin and that there is high price elasticity for global medical care. Few have found the magic key that fits the lock that opens the doors to profits. Payors and employers are hesitant to accept the value proposition without a better way to reduce their risk and demonstrate tangible, meaningful cost savings to their insureds and employees.

Global healthcare IT connectivity and integration 

The US national healthcare information architecture is evolving. Eventually, the network will be a portal to the world and will allow for seemless, secure, confidential transfer of personal health information thus assuring some continuity of care and quality improvement. Similarly, it will take a while for health information systems to evolve in host countries that can talk to non-host systems. Short term solutions, like personal health records or mobile health applications, might fill the void temporarily.

A physician generated global healthcare referral network

Most medical tourism  models  connect patients to healthcare facilities, bypassing doctors in the initial stages. Docs will get in the game when the model feels better, and they have the resources and ability to make referrals to consultants directly, like they do now. Given the rise of international members, professional medical societies should be more proactive in building global referral networks, rather than seeing them as threats to existing domestic members.

A global regulatory, legal and socioeconomic ecosystem

The barriers to adoption and penetration of medical travel are many and include liability, reimbursement, quality assurance and impediments to continuity of care. As healthcare goes global, so will the rules and regulations that facilitate or obstruct its use. How about a World Trade Organization Treaty on Medical Travel?

Patient awareness and acceptance

According to the most recent polls, 50% of consumers understand the meaning of the term "medical tourism", leaving home for care. Social network buzz and media stories find the medical travel story sexy, particularly given all the noise about escalating healthcare costs and consumers, employers and payors are hungry for more information. Moving patients from awareness to intention to decision to action, however, will take more time and use innovative marketing approaches directed towards granular market segments.

Global medical travel  is projected to be a $1B industry by 2012. While the bones are in place, it wll take more time to add the flesh. Until then, to quote Karl Mauldin, people won't leave home without it.

Medical Travel Is Not Just About The Cost

3 Million people spent $76B finding care away from home this year.

According to a recent Frost and Sullivan research report on the medical travel business, medical tourism wil grow to be a $100 B business by the end of 2012. Hot spots include the Middle East, Asia and Germany.

Most people think cost is driving the traffic. However, a McKinsey and Company 2008 report also emphasizes that 40 per cent of medical travelers seek advanced technology, while 32 per cent seek better healthcare. Another 15 per cent seek faster medical services while only 9 per cent of travelers seek lower costs as their primary consideration.

As reimbursements for Medicaid and Medicare continue to decrease, more and more US doctors indicate they will cut back seeing patients insured by these government insurance plans,  or stop seeing them altogether. This will further fuel access, not cost , to the forefront of medical travel.

Inbound tourism is the flip side of the same coin. As US healthcare continues to get more expensive and more difficult to access, hospitals are looking for ways to fill the beds, and foreign patients fit the bill, and pay it in cash.

As I've pointed out before, these market eruptions present entrepreneurs with big opportunities. Healthcare reform might change the rules, but I don't think significantly, given the big picture patient demographic and manpower supply and demand challenges.

Global referral communications, coordination and care is a growth industry begging for talent and $100B is likely to get a lot of attention. It certainly got mine. (http://www.medvoy.com)