The Coming Recession’s Impact on Medical Tourism

In last Sunday’s edition of the Wall Street Journal (http://tinyurl.com/2ajqjny), Arthur Laffer wrote an article predicting a double-dip recession beginning in early 2011.  Laffer is a supply-side economist who served in the Reagan administration.  He is one of the few who theorized that lowering tax rates actually increases tax revenues, a theory that has so far proven true every time it has been tried, including the tax cuts of presidents Kennedy, Reagan, and Bush.

Laffer’s reasoning is based on the fact that the Bush tax cuts are set to expire at the end of this year.  Thus, at the beginning of 2011 tax rates go up automatically for income, capital gains, and inheritances.  Simultaneously, state and local tax rates are going up all over the country as laws passed this year go into effect next year.  He claims that this pattern will cause numerous businesses and individuals to shove as much income into 2010 as possible in order to avoid the higher taxes next year.  The effect on next year will result in a sharp decrease in tax revenues as well as business profits.  The dire consequences, according to Laffer, will be a collapse of the U.S. economy.  In Laffer’s words, “When we pass the tax boundary of Jan. 1, 2011, my best guess is that the train goes off the tracks and we get our worst nightmare of a severe ‘double dip’ recession”.  Laffer may be on to something here.  Why in the world would we increase taxes at a time like this?  Perhaps a more reasonable policy will prevail, especially if the Republicans take back control of both houses of Congress.

If Laffer’s predictions come true, what will be the effect on the medical tourism industry?  If I had to guess, I would bet that it will have a negative impact.  If he is correct, we’ll see an increase in small businesses going bankrupt and fewer entrepreneurs starting new business ventures.  More and more failed business owners, along with their employees, may find themselves qualifying for Medicaid and county assistance programs.  Such a trend means fewer people having the resources, or even the need, to travel overseas for medical care.

I hope my analysis is completely wrong, but my sense is that it’s not.  I’m curious to see what others think.

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Book Review: State of the Heart

I just finished reading the book, State of the Heart, by Maggi Ann Grace.  The book chronicles the experiences of Howard Staab, Escort Heart Institute’s very first patient from the U.S. back in 2004.  While told in 3rd person about Staab, it is much more about the experiences of the author, who accompanied Staab on the journey to New Delhi.  It is nevertheless a fascinating read.  Having been to New Delhi as a medical tourist, both to Apollo Hospital for surgery and Escorts Heart Institute (EHI) for a CT Stress Test and a Colonoscopy, I could relate to most of what Grace had to say.  Those having regularly read my blog by now know that I developed a close friendship with Dr. Vijay Kumar, one of the cardiologists on staff at EHI.  On my first visit to the hospital, he gave me a personal tour, taking me in and out of ICUs, Operating Theatres, Recovery Rooms, CCUs, and patient rooms.  As Grace described Staab’s ordeal of going through two Operating Theatres and two Recovery Rooms, I was able to paint a vivid picture of the scenes in my mind, recalling the walk-through with Dr. Vijay, as he likes to be called.

She speaks of the oppressive heat of New Delhi, of the uniformed guards positioned by the elevators on every floor of the hospital, of being the only Caucasian in a sea of dark-skinned people who mostly speak a different language, of the incredible hospitality of the Indian people, and of the unbelievable poverty of some of New Delhi’s residents.  Having been to New Delhi, I connected well to her insights.  She spoke of the great food at Escorts, one of the few things to which I could not relate.  As an inpatient, I spent two nights at Apollo Hospital where the food was mediocre at best.  Okay, I’m digressing a bit.

The author does an excellent job communicating how expensive the cost of healthcare has become in this country.  She tells us that the valve replacement needed by Staab might run as much as $200,000 at nearby Durham Regional Hospital.  She was able to find a deal in Houston, Texas for about $45,000.  At Escorts, the whole price tag, not including travel, was just under $6,000.

The book also underscores the need to have a travel companion whenever going to a foreign country for a medical procedure.  For instance, Staab likely had several mini strokes after being discharged but before traveling back home.  Without Grace by his side, he might easily have found himself in serious trouble.  Furthermore, I became keenly aware that Staab and Grace leaned very heavily upon each other for physical and emotional strength.

After returning home to North Carolina, Grace related a post-surgical episode requiring a 2-day stay at nearby Durham Regional Hospital.  Given that the memory of their experiences at EHI was less than three weeks old, she was able to point out the differences in the quality of the nurse care between the two facilities. The contrast quickly became apparent when Grace told of having to change Staab’s bed linens, retrieving her own sheets from the nurses’ closet.  The trips to the ice machine also stand as unspoken reminders that she is no longer in India.

Grace closes the book with poignant praise for India and an implied challenge for the U.S. healthcare system.  In her words, “India, the land of contradictions.  Organized chaos.  A third-world country with first-world state-of-the-art medical care available for a fraction of the cost of the same procedures here in the U.S.  India, where the nursing care is unmatched by any I have experienced in American hospitals – where some nurses make the equivalent of $1.38 (U.S. dollars) per hour, and care for their patients as if they made thousands.  India, where the generosity of the people is palpable, in the face of poverty we will never know.”  Having been there as a patient, I wholeheartedly concur.

The book is not without its shortcomings.  For instance, I was disappointed that Grace didn’t go into detail about how Staab decided on EHI.  She rather glosses over that section, giving the presumably false impression that the decision was based on emotion rather than hard data.  More insight into this process would have been nice, perhaps helping others in their own evaluations.  Given that Staab was the very first American treated at EHI, I get the impression that he and Grace were pioneers in the medical tourism arena.  As such, you won’t find in the book certain concepts you might take for granted today, such as choices among medical facilitators, Joint Commission accreditation, and having an independent representative act as an advocate on your behalf.

I was also a little put off by the strange spirituality practiced by Staab and Grace.  As someone holding a strong faith in the God of the Hebrew Bible, I had a hard time relating to the eastern faith, or lack thereof, as expressed by the author.  She also made a few sexual references that really didn’t add anything of substance to the book and might have been better left out.

My minor criticisms aside, the book is a great documentary.  I highly recommend it.

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A Post-Op Infection, or Was it?

After more than a week-long absence, I’m glad to be back, having been kept down by illness.  On Friday, May 21, the date of my last post, I began noticing a fever.  Well, the fever kept climbing, the chills set in, the headaches came on strong, and the body began to ache all over.  After a couple of days, I thought maybe a post-op infection had developed.  Last month, Dr. Prasad told me to do no heavy lifting for 6 weeks after the surgery.  On Wednesday, May 19, I played volleyball with my congregational family.  Unfortunately, that was only 27 days since the surgery, not the six weeks dictated by the good doctor.  The thought occurred that maybe I had torn something inside and that two days later, an infection formed.  A quick email to Dr. Prasad and a follow up response alleviated that fear.  He said that the chances of an infection this far past surgery were fairly remote.  The only other explanation was the flu. While that bit of news was comforting, I was now way too late to try Tamiflu.  Going to the doctor also seemed to be a waste of time.  About all he would likely tell me would be to stay in bed, drink plenty of fluids, take 2 Tylenol every 4 to 6 hours, etc., etc., etc.  I was already taking those steps.  The thought also occurred that maybe this was H1N1, a.k.a., the Swine Flu.  Who cares?  It’s still the flu.  What difference does the strain of the virus make?  It all feels the same.  The treatment is no different.  Having one more case in the government database won’t make a difference.  Therefore, the hassle of finding out the specific type of flu simply didn’t seem worth the effort.  Now that the symptoms are finally subsiding, I plan to get back to writing.

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Looking for a Medical Tourism Insurance Plan

After returning from India a few weeks ago, I had an idea for an affordable insurance product.  Why not offer a plan to Americans where most major medical procedures would be performed in another country, such as India, Costa Rica, Brazil, Malaysia, or Singapore, at a Joint Commission accredited hospital.  If you needed surgery, for example, the plan would cover the cost of the patient’s travel expenses plus that of a companion, in addition to covering the cost of the medical care itself.  For emergency services, cases where the patient cannot travel, and cases where the cost of travel to another country outweighs the cost savings, the plan would need to provide coverage for care with a U.S. health provider.  Thinking logically, the cost of such a plan would seem to be highly affordable to most Americans.  Does such a plan exist?  I have looked but not been able to find one.  Perhaps an insurance executive will read this post and be the first to offer up one.  Hey, I can dream can’t I?  If someone knows of such a plan, I would love to stand corrected.

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A Medical Tourism Group Asks Some Great Questions

A few days ago, someone from an India-based medical tourism company saw my blog and wanted some comments to use for its website. Some of the questions are worth repeating. The first question asked was, “what made you choose India as compared to other countries which are closer to the U.S.” In actuality, I had hoped to go to Costa Rica, Brazil, or Panama. All of these are in the same or adjacent time zone and only a few hours from Atlanta by air. Unfortunately, none of the hospitals I contacted in those countries ever followed up with me. One medical tourism company encouraged me to consider going to Panama but never came back with a proposal, even after requesting one a second time. I also found that the websites of the hospitals in those countries were not user-friendly toward English-speaking, international patients. By contrast, the hospitals in India were anxious for me to come there. One even called me on the phone, not once, but twice. My conclusion was that India’s hospitals were geared toward medical tourism while those of Brazil, Costa Rica, and Panama were not.

The India-based medical facilitator also asked how I would rate India, Apollo Hospital, and my surgeon, Dr. Prasad. Since I haven’t been to other developing countries, I’m not sure answering it would be a fair judgment. Furthermore, I only saw New Delhi and wasn’t able to compare it to the rest of the country. I can tell you that New Delhi has many modern amenities and a decent infrastructure. Nevertheless, that infrastructure has much room for improvement.

In rating the hospitals, Indraprastha Apollo Hospital is one of only twelve Joint Commission-accredited facilities in the country. Two more are located in New Delhi – Escorts Heart Institute and Moolchand Hospital. Of these three, Apollo and Escorts were both excellent choices. However, Moolchand is not one I would recommend. Another hospital, which is not JCI-accredited but is a very modern and advanced facility is a place called Medanta Hospital, located just 10 minutes from the airport. Without accreditation, I probably wouldn’t choose to be treated there. Medanta is in the process of obtaining accreditation, but being only 6 months old, the process will likely take a while longer. Having toured the place, I would be very surprised if it didn’t obtain it.

Dr. Prasad was an outstanding surgeon. Two other physicians stated emphatically that Dr. Prasad was an excellent choice. Each of them had something to gain by discouraging me from choosing him, yet they didn’t hesitate to encourage me to go ahead with the surgery under Dr. Prasad’s care. During the initial consultation he took the time to explain what to expect. In addition, his bedside manner was better than most American physicians I’ve seen. Lastly, he responded very quickly to all email communications.

The last question asked for do’s and don’ts to share with medical patients coming to India for treatment. Here are some do’s:

  • Bring a power converter for your 110v appliances (laptops and cell phones should be able to handle the 220v of India)
  • Bring a travel companion with you if your budget can afford it
  • Notify your bank and credit card company that you’ll be traveling to India so that you can use your credit card and ATM card in India
  • Leave extra room in your suitcase to bring back any items you might purchase
  • Drink plenty of water in India as the temperature soars to 105 degrees (42 Celsius) everyday
  • If you have a GSM world phone (AT&T or TMobile), contact your cell phone provider and ask for an unlock code
  • Purchase a SIM card from a local phone provider, such as Airtel or VodaPhone to use in your U.S. phone, if it is a GSM world phone and your cell carrier gave you an unlock code
  • Purchase a block of minutes for your phone – 600 Rupies worth should be sufficient (about $15)
  • Be prepared to wear a mask if the pollution bothers your respiratory system
  • Carry an appointment book showing names, addresses, and phone numbers of all places you need to visit
  • Bring a camera as you’ll likely want to take lots of pictures
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    Finally, here are some don’ts:

  • Don’t convert your U.S. cash at a money changer – get Rupies from the ATM machine instead
  • Avoid going outside during the afternoon hours, if possible
  • Don’t forget to look to the right when crossing a two-way street as India requires people to drive on the left-hand side of the road
  • Don’t run your laptop on AC power, except to recharge the battery – the 220v will cause your laptop to run so hot that you might kill your hard drive
  • Don’t drink water from the tap – use bottled water only
  • Don’t consume any unpackaged food from a street vendor – these types of foods should only be purchased from restaurants
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    The Importance of JCI Accreditation

    In previous posts, I have stressed the importance of choosing a hospital that is accredited by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO). While the American designation is known as JCAHO, the international equivalent is called JCI, or Joint Commission International. Why is this designation important? The reason is simple. JCI-accredited hospitals in other countries must meet practically the same standards as U.S. hospitals, which are also Joint Commission accredited. I say “practically” because laws in other countries vary and have to be taken into account when accrediting the hospitals in those countries. Still, such differences should be very minor.

    The Joint Commission is the accrediting body for most acute care hospitals in the United States. Most states in the U.S. require that their hospitals be accredited by JCAHO in order to meet licensure requirements and to be eligible for Medicaid reimbursement. Simply put, without JCAHO accreditation, they will likely go out of business. Having worked in the hospital industry for 18 years, I remember when Joint Commission came to town. Just about everything except that which was necessary for taking care of patients was put on hold for a few weeks in order to meet with JCAHO officials and provide them with whatever they needed to make their assessment.

    The types of standards created by the Joint Commission include those for patient rights, patient safety, medical staff credentialing, performance improvement, patient confidentiality, pain management, informed consent, and a whole lot more. While the JCI designation does not guarantee quality service, it is definitely a good indicator than you can expect high quality. It is a tough designation to achieve. Out of the thousands of hospitals in India, for instance, only twelve of them have it. The ones who have earned it have undergone intense inspections, testings, and interviews. That’s why I would be very hesitant to choose a facility without it.

    To learn more about JCI accreditation, check out http://www.jointcommissioninternational.org.

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    Would I Do it All Over Again?

    After having gone through this entire odyssey, which began with a night of intense pain last September and ended on April 16 with surgery halfway around the world, the thought many have expressed and probably many more have kept to themselves, is whether I would choose the same course again, knowing what I know now. Many in the U.S. for a long time have believed that our healthcare system is the best in the world. All factors considered, that assessment is probably correct. However, one can find excellent health care beyond the borders of this great nation at a fraction of the cost found here. The downside is that to get it, you typically have to travel to developing countries. Such nations are not first world, but neither are they third world. They are typically nations in transition. You’ll find many modern conveniences there, but you’ll also find tremendous poverty and an infrastructure that lags behind the U.S. Such countries may not even be clean by U.S. standards, but neither are they filthy. What I found in India was a nation lacking in laws pertaining to proper zoning, the practice of littering, clean air, and traffic enforcement. These deficiencies were not deal breakers for me and probably not for most people. I am confident that these things will improve over time, perhaps after a generation or two.

    The fact remains that the quality of care provided to me by the private hospitals in New Delhi was second to none in the U.S. Several other hospitals in India probably would have given identical care, but one can only test the services of a sample of hospitals and other health providers. My sense is that the care one might receive at private hospitals in Costa Rica, Brazil, and Panama would rival that of India. However, the cost is likely to be slightly higher in those places, yet still much cheaper than in the U.S.

    Knowing what I know now, the answer to my original question is, ABSOLUTELY, and without hesitation. Would I make any changes to the process? Most definitely. For starters, I would hire a patient advocate, who speaks excellent English, to accompany me to all hospital appointments in order to interface with hospital staff in making payments, ordering medications, and processing through outpatient service areas. Secondly, I would insist on a guaranteed price for the surgery. While the actual cost remained a fraction of the U.S. estimate, it was still $500 more than originally quoted, amounting to a whopping 25% in additional fees. Third, I would convert very little cash on arrival. Instead, I would get 95% of cash needed directly from the ATM. For example, the exchange rate in April 2010 was 44 Rupies to the U.S. dollar. By the time the money changers added in all their junk fees, the effective rate of exchange was somewhere between 35 and 39 Rupies to the U.S. dollar. The effective exchange rate at the ATM, on the other hand, was about 43 Rupies to the U.S. dollar, which was much closer to the published exchange rate of 44 Rupies. The ATM essentially removed the middle men and their added costs. Finally, I would like to have been better prepared to deal with the air pollution. After two weeks of breathing in the dust and pollution, my body began to suffer. Next time, I plan to wear a breathing mask, use a face cloth, and/or take medication to better handle the problem.

    What would I not change, if doing everything over again? Because of all the research that went into this effort, I made many good decisions before ever arriving in India. My choices of airline, accommodations, and medical providers were all excellent ones. Continental offered a direct flight from New York to New Delhi, thus avoiding the problems many people had connecting through Europe due to the volcanic ash cloud. The flight attendants were all Americans who treated us very well. They also provided free in-flight entertainment, two tasty meals, and free power for my laptop. Sai Villa Bed and Breakfast (http://www.saivilla.com) offered the best value in New Delhi – location, price, service, spacious common areas, food quality, free wi-fi, and comfort. Dr. Sharad Kapoor (http://www.dentalremedies.com) was an excellent cosmetic dentist. What more can I say about him? Both Apollo Hospital (http://www.apollohospdelhi.com) and Escorts Heart Institute (http://www.ehirc.com) are Joint Commission accredited facilities, meaning that they must meet the same standards as their U.S. counterparts. The compassion demonstrated at each hospital matched and possibly exceeded that which would have been provided in the U.S.

    Going forward, I would like to purchase a medical insurance policy that provides coverage for most inpatient services as well as expensive outpatient treatment by sending the patient and a companion to a Joint Commission accredited hospital in India, Costa Rica, or Brazil. When travel is not practical, the plan should provide coverage at local hospitals. Does such a policy exist? I don’t know. But if it did, the cost would surely be a fraction of traditional U.S.-based plans. If it does exist, I hope to find it. Perhaps in the age of Obama-care, when insurance premiums and hospital costs are likely to skyrocket, we’ll begin to see a dramatic increase in people seeking care beyond our borders. If so, I believe insurance companies will increasingly offer the type of policy I’m currently seeking. Only time will tell.

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