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.

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.

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:

Finally, here are some don’ts:

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.

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.

A reporter from a Malaysian newspaper found my blog last week and asked for an interview. She must have done a lot of searching to find it because I performed all kinds of searches on Google and WordPress using terms like medical tourism, health traveler, and the like. However, I gave up after clicking through page after page yet never finding it. Hundreds, perhaps thousands, of other entries appear to ahead of mine. Either she is very patient or very sharp with search terms or both. Well, she is a reporter, and good ones are trained to dig for information.

Having found me, she interviewed over FaceBook chat. She definitely did her homework as demonstrated by her questions. She knew exactly what to ask throughout the process. Her final product turned out to be a piece on the booming trend of medical tourism to Asian countries told through the experience of one person. It was a very interesting and compelling account.

In case you’re interested in reading it you can find it here - http://thestar.com.my/health/story.asp?file=/2010/5/2/health/6152063&sec=health.

After passing through customs in Newark, New Jersey and rechecking my bags for the last leg of the flight to Atlanta, I found a small coffee shop close to the gate of the next flight. I decided to sit at one of the three small tables, practically crammed up against the counter in this modest establishment. Still, I didn’t mind because the closeness brought me right up next to other Americans who might want a cup of Joe at this early hour. Not speaking to a single one in two weeks makes one slightly homesick for his fellow countrymen. Hearing the voices of other Americans is music to my ears, even if it does carry a New Jersey accent.

Flying back to Atlanta, the plane is so empty most people have a row to themselves, mine included. As we near Atlanta, I can tell we’re in North Georgia even before the pilot makes the announcement that we are on final approach to our destination. On the way down from New Jersey, my seat is on the starboard side of the plane, looking west. For most of the flight, the Appalachian Mountains are down below. Suddenly, they give way to rolling hills and a large reservoir. That would be Lake Lanier with dozens of tiny islands dotting its silhouette. Lake Lanier is the body of water nestled at the foot of the Appalachian Mountains that supplies most of the Greater Atlanta area with its drinking water.

As we pass it by, I can spot what appears to be I-985. My thoughts go to friends who live up this way. Sharon lives over there in Cumming. The Gottfrieds are probably just off to the west from this location. Further south we pass the intersection of I-85 and I-985. I know that Georgia Highway 316 must be close by. There it is, just to the west of the plane. The next major road up must be Sugar Loaf Parkway. Yes, indeed it is, and I see the building where my good friend Tim works. If I could call him, I’d tell him to look up. Still heading south, Stone Mountain is now just to the west. We must be no more than 10 miles away from it. That would probably put us right over the top of my rabbi’s house, that of Derek Leman. Indeed, I’m starting to feel at home already.

Taking the train from the airport, we’re headed off to the other end of the line at North Springs station where my family will greet me. The flight arrived so early that for them to come to the airport would have meant going through the worst of rush hour traffic. Therefore, we agreed on the train station. Seeing them after two weeks brings a feeling of incredible joy. My daughters Hayley and Abby won’t stop hugging me, but that’s just fine with me. Aaron is happy too, but he’s sixteen years old now and becoming his own man. As such, he’s too old for expressing himself in the likeness of his two sisters. My wife Julie is very happy to see me, perhaps relieved is a better word. Being in their presence and holding them close makes one realize that of all our possessions in this world, nothing is as valuable as the ones we love. I want to cherish this moment and make it last as long as possible.

From there, we stopped off for a late breakfast / early lunch where we could sit and talk about the trip. They were full of questions, wanting to know every detail. Time slips away as we enjoy each other’s company. On the way home my daughters insist that I sit in the back seat in between the two of them. Obliging them, they snuggle up close to be with their Papa.

Driving home, I notice that Spring Time is now in full swing here in North Georgia. The Bradford Pears, Japanese Cherries, and Dogwoods (various species of trees) have all lost their flowering blooms and have been replaced with green leaves. At least the azaleas are in bloom. The temperature is noticeably 30 degrees cooler (15 degrees cooler on the Celsius scale). Arriving home, the green grass and azaleas stand in stark contrast to the heat, the dust, and the lack of greenery in New Delhi. Once again, I am reminded of how grateful I am for the life we have here in the U.S. It feels good to be home.

Waking up this morning was a bit of a challenge.  For the last few days, my body has felt quite tired, achy, and stuffy.  After Dr. Vijay left last night, I went straight to bed.  Crawling out of bed, my chest is hurting, noticeably so as I move around.  Am I having a heart attack?  The pain is centralized around my heart area, but it is not extending to either arm or even my neck.  My thoughts turn to possible causes.  The CT stress test from last week showed a very healthy heart, so a heart attack seems unlikely.  Maybe the daily 105-degree heat (42 degrees Celsius), pollen, and pollution combined with the surgery are taking their toll on me.  Suddenly, I remember going to the pharmacy and picking up some cold medicine last Sunday.  Here, you don’t need a prescription.  You simply tell the pharmacist what the problem is and he’ll recommend something appropriate.  He told me to take one per day.  However, since one-a-day didn’t seem to be working, I increased the dosage to twice per day.  A number of cold remedies might, in fact, cause some heart pains.  I remember years ago taking a new allergy prescription that has since been pulled off the U.S. market due to the fact that a few people died of heart failure after taking it.  That particular medication was making my ticker become off-kilter way back then, even before anyone knew of its deadly side-effects.  Instinct told me to quit taking the medication, which I did.  Only months or years later did the FDA issue its ruling.

My thoughts return to the medicine purchased from the local pharmacy.  Could it be the same pharmaceutical that the U.S. Food and Drug Administration banned years ago?  Not taking any chances, I contacted both Drs. Prasad and Vijay.  They both recommended discontinuing the medication.  They also suggested that the combination of the oppressive heat, physical stress, dust, and pollution might also be the cause.  That might explain why so many people here travel about with a cloth covering their faces.  The two doctors may be correct in their assessment because sitting outside on the patio at Sai Villa for the last couple of days has been rather difficult.  Therefore, I spent most of Sunday and Monday indoors, limiting any time outside to brief periods.

For my last day in New Delhi, I ask one of the hired servants, whose name is Luxman, to accompany me to the nearby market in order to pick up some Indian tea and spices (so much for staying indoors).  A favorite beverage for the locals is chai, a mixture of tea and milk.  He patiently taught me how to make it this morning before heading off to the market.  On the way, he tells me about his wife and two children back home in Calcutta.  “How often are you able to see them,” I asked.  He answers by saying he works at Sai Villa for one month, then goes home for a month.  Life is certainly different for many here, again making me greatly appreciate the life I have in the U.S.

Luxman is the head servant, leading a team of three.  Throughout my stay at Sai Villa, he has been at my beck and call whenever needed, never hesitating to fulfill any request, such as running errands, ordering meals, handling my laundry, and preparing chai.   He even let me teach him how to make scrambled eggs American style.  However, he never quite mastered the art as he wants to cook the eggs more like an omelet, then chop it up into tiny bits, in spite of my pleas of “no chop.”  At least he let me cook them once while he watched, thereby allowing me to enjoy them the way I like them – slightly moist and chunky instead of dry and in minuscule pieces.  Too bad he’s vegetarian.  Otherwise, he could actually taste the difference.  At least he tried.  Ashutosh is fortunate to have found such an excellent worker.
  
Since my flight departs so late in the evening, Ashutosh allows me to have a very late checkout.  After packing, then taking a late afternoon shower, I finally checked out of my room at 5:00pm, then ordered an early dinner, which in India is really a late lunch.  Finally, at 6:45pm, my cab arrives to take me to the airport.  On the way, I try to take in the sights and sounds of India one last time.  We arrive at the airport at about 7:30pm and learn that back at Sai Villa, it has started to rain.  Too bad I couldn’t be there to see and enjoy it, but I am happy for the people, all the same.  They deserve a respite from this oven.