Outsourcing to India hip surgery
By Felice J. Freyer
Journal Medical Writer
When Anne Grant needed surgery on a painful arthritic hip, she didnâ€™t go to a hospital in Rhode Island. She didnâ€™t even go to Boston.
Instead, she packed her bags for India.
Yes, India â€” where Indian doctors and nurses performed the procedure that Grant wanted for a fraction of the cost in the United States. Five months later, the 61-year-old Providence woman says sheâ€™s walking and swimming without pain.
As surprising as her choice may seem, in heading to India, Grant joined tens of thousands of other Americans who are going overseas for medical care â€” to India, Thailand, Brazil, Singapore, to name a few places.
The first such travelers were looking for cut-rate cosmetic surgery. But today, many include people seeking necessary procedures, including heart bypasses, hip and knee replacements, cancer treatment and dental work.
They are finding clean, well-equipped, even luxurious hospitals that meet accreditation standards and often are staffed by American-trained doctors. Catering to an international clientele, they provide procedures at roughly one-tenth to one-quarter of the cost in an American hospital.
â€œOur research showed us a very large group of aging baby-boomers were beginning to age into expensive treatment without being able to pay for it,â€? said Josef Woodman, author of a new book on the trend called â€œmedical tourism.â€? Many are too young for Medicare but donâ€™t have insurance â€” and theyâ€™re looking for help overseas.
Woodman estimated that last year, 150,000 Americans went abroad for medical treatments. Based on interviews with travel agents and reports from international hospitals, Woodman made the educated guess that half sought dental care in Mexico and cosmetic surgery in Brazil or the Caribbean, and the other 75,000 went for major, necessary procedures at international hospitals in Asia.
While those numbers are small, Woodman is among many who are convinced that medical travel is going to boom. Already, medical-travel agencies have sprung up around the country, offering to find hospitals, schedule surgery and arrange flights and accommodations.
ANNE GRANT IS far from the flighty or desperate type you might imagine hopping a plane to get surgery in India. Sheâ€™s a prominent person locally â€” ordained minister, social activist and writer, former executive director of the Womenâ€™s Center of Rhode Island, and the wife of H. Philip West Jr., former director of Common Cause of Rhode Island.
Grant had long suffered from pain in her back and knees, and in her mid-50s she started noticing that her right hip would lock in place. Grant found herself increasingly hobbled, wincing at ordinary movements like getting into the car or climbing the narrow staircase of her South Side house. An orthopedist she consulted years ago offered no help.
Then, at a dinner party last year, her friend Lisa Grant â€” a neighbor, but no relation â€” mentioned that she, too, had a bum hip, and she was going to Belgium to have it fixed. From a 60 Minutes episode, Lisa Grant had learned about hip resurfacing, a new approach to hip replacement that preserves more of the thigh bone and is reputed to last longer. (See related story.) Although performed in Europe for more than 10 years, hip resurfacing is new in the United States, having received FDA approval only in May 2006.
Lisa told Anne about firstname.lastname@example.org, an Internet listserv rich with patientsâ€™ reports of their hip-resurfacing experiences.
Anne Grant carries a snowy-white laptop around the house; sheâ€™s at home with Internet research, and after talking with Lisa, she plunged in. One participant in the â€œsurface hippyâ€? group supplied Grant with a spreadsheet on eight doctors who do hip resurfacing, detailing the participantâ€™s own accounting of each doctorâ€™s price, number of procedures completed, length of incisions and percentage of procedures that required corrections.
Grant e-mailed her x-rays to two American doctors, as well as Dr. Koen De Smet, the Belgian doctor who operated on Lisa Grant, and Dr. Vijay Bose, in Chennai, India. All wrote back saying that she was a candidate for the surgery, but Bose sent the most detailed letter, discussing the advantages of hip resurfacing, referring her to Web sites and even advising her on how to cope with her arthritic knees. He also had the lowest price â€” just $7,000 for the surgery.
Doctors overseas had more experience with hip resurfacing than most American doctors, including the one who was just starting to offer the procedure at South County Hospital. In any case, no doctor in her insurance companyâ€™s network was doing hip resurfacing. By going out of network, Grant would have to pay 30 percent of the surgeryâ€™s cost. Although prices vary by region, and insurers reimburse at different rates, in the United States hip resurfacing is said to cost $35,000 to $40,000.
Impressed with what theyâ€™d learned, and eager to visit Asia, Grant and her husband, West, decided to book the surgery with Bose at the Apollo Hospital in Chennai, part of a chain that runs 41 hospitals in and near India.
Grant says her primary-care doctor supported her decision. But when she went for inoculations at the travel clinic at Miriam Hospital, the doctor there was dismayed. â€œDo you know how many infectious diseases India has?â€? Grant recalls the doctor cautioning.
But West and Grant had traveled in Africa, where there are also infectious diseases. And their research indicated that the Apollo Hospital was clean, if not cleaner, than any in America. â€œI didnâ€™t have a fear of going there and it may have been because so many people were so enthusiastic about their experience,â€? Grant says.
WHEN GRANT and West landed in Chennaiâ€™s airport on Jan. 16, a free car sent by the hospital whisked them away from the squalor all around. In her personal blog about the trip (http://maudandme.blogspot.com/), Grant described shantytowns that were â€œacres of rusted scrap and splintered wood,â€? clothes that â€œhang to dry in murky gray smog,â€? barefoot children, and scrawny goats nibbling grass growing in sewer effluent.
At the hospital, Grant and West were escorted to the â€œPlatinum Wardâ€? for international customers. Her spacious room came equipped with an electric bed, refrigerator stocked with bottled water, microwave, plasma TV and a couch for her husband. A dietician popped in to check on Grantâ€™s food preferences â€” Indian or Continental cuisine? A man swept the floor twice a day.
Grant evinces conflicted feelings about the luxury sheâ€™d enjoyed. She knew that Indian customers donâ€™t get the electric beds. She also talked to the staff and learned they work long hours for little pay, and thatâ€™s one reason why the hospital can offer such attentive care at a low price.
But, Grant says, the nurses consider it a career-boosting privilege to work in such a hospital, and nobody complained. In the end, Grant hesitantly concluded that her dollars would benefit Indian society. For example, Bose, her surgeon, makes enough money that he can work for free at the government hospitals that serve the poor.
After preoperative tests, Grant met with Bose, who described the hour-long procedure he would do the next day.
Grant awakened after surgery to exclamations of â€œperfect!â€? and happily fell back asleep. Over the next few days a physical therapist taught her the exercises sheâ€™ll need to perform, and helped her walk. On the fifth day, they left for a beachside resort south of Chennai, where she would spend a week, resting.
Grant returned for a final checkup with Bose before boarding the 26-hour flight, arriving home two and half weeks after leaving.
At home, she says her recovery was swift and painless. On her 61st birthday, 45 days after surgery, she resumed swimming. She retired her crutches within two months of her return. And now, with her hip fixed, she finds that her back and knees feel better, too.
The bill for this care came to $7,029. The biggest expense, $2,475, was the device implanted in her hip. The surgeon was paid $1,028. The radiologist got $50; the cardiologist, $11. Adding plane fare and accommodations for herself and her husband, Grant estimates she spent a total of $11,600. Her insurance company reimbursed $5,300.
IF THIRD WORLD hospitals can offer care as good as the care at home at a fraction of the cost, what is the implication for American hospitals? Will they be forced to compete in a global marketplace, despite the built-in costs of the American health-care system, such as high wages and malpractice premiums?
Local doctors and hospital executives, when asked about medical tourism, were both appalled and unconcerned: they raised the specter of gruesome infections and insisted that medical travel wonâ€™t attract enough people to affect hospitals here â€” especially not in a state where for many â€œforeign travelâ€? means a trip to Boston.
So far, it appears theyâ€™re right, at least about Rhode Island. Dr. Augustine A. Manocchia, chief medical officer of Blue Cross & Blue Shield of Rhode Island, says the insurer hasnâ€™t yet had any claims for overseas medical care â€” though he added that Blue Cross would consider it as a low-cost option if patients wanted it.
Similarly, Dr. John R. Lonks, an infectious-disease specialist who works in the travel clinic at Miriam Hospital (he was not the doctor who vaccinated Anne Grant), said he had not encountered any travelers who were going abroad for necessary procedures. But he has treated some who went to the Dominican Republic for plastic surgery and came back with serious infections.
Asked about Americans seeking cheaper care overseas, Lonks said, â€œYou get what you pay for.â€?
He raised numerous concerns. â€œWhat happens if you have the procedure, come back to United States and you develop a complication? Whoâ€™s going to take care of it? Will your insurance cover it? â€¦ How do you know about the sterility and quality of their equipment? How about if you need a blood transfusion in India? â€¦ How about malaria? â€¦ How about typhoid or measles? Measles is a common disease in India.â€?
In an e-mail responding to The Journalâ€™s questions about the risk of infections, Grantâ€™s surgeon, Vijay Bose, said that â€œthe patients are in a protected environmentâ€? and called the chances of catching something like malaria â€œvery remote.â€?
â€œOver the last three years where I have been doing a large volume for American patients, we have not had a single case of malaria or other infectious diseases,â€? Bose wrote. He also said the hospitalâ€™s blood bank is comparable to any in Europe or North America, so patients who need a blood transfusion face the same low risks as anywhere. (Grant did not need any blood.)
As for the low cost, Bose had this comment: â€œI personally do not think that the cost is cheap in India. It is just the actual and appropriate cost for various procedures. The converse is true, it is artificially boosted and very high in the U.S.
â€œThere are many reasons for this of course but one of the main ones is the malpractice premiums. The doctor-patient relationship is much more friendly here with a lot of trust.â€?
The flip side of this, however, is that patients who suffer medical malpractice overseas will have a hard time collecting compensation because of weak malpractice laws. Returning home after just a few daysâ€™ recuperation, patients are on their own finding follow-up care if they need any. Also, they usually have to pay the full bill out of pocket, and then attempt to collect some reimbursement from their insurance company, if they have one.
THE APOLLO Hospitals Group and most other hospitals that cater to international patients have been accredited by the Joint Commission International, an arm of the same agency that accredits American hospitals. Dr. David Jaimovich, chief medical officer, said that the JCI has accredited 125 hospitals in 23 countries, and expects that number to double within a year â€” driven, he said, not just by medical travel but also growing interest in safety and quality around the world.
Jaimovich said JCI criteria are not identical to those used in U.S. hospitals, but they represent â€œall the safety and quality requirements embedded in international standards.â€?
Does that mean JCI-accredited hospitals are just as good as those in America? â€œItâ€™s very difficult to answer that,â€? Jaimovich said. â€œIn the United States you canâ€™t say that two hospitals that are accredited are equal also.â€?
Woodman, the author of Patients Beyond Borders: Everybodyâ€™s Guide to Affordable, World-Class Medical Tourism, visited hospitals around the world while researching his book, including dropping in unannounced. â€œThe JCI-accredited hospitals were, to a one, jaw-dropping,â€? he said. â€œYou could eat off the floors. They were efficient. Most of the staff spoke English. International patient centers are very customer-driven.â€?
In contrast, he said, many American hospitals â€œare in sad shape, with rushed doctors. â€¦ The customer service is lacking. Staffs are getting driven down to the bone.â€? Medical tourism, Woodman says, â€œwill be a catalyst for change.â€?
Change, indeed, is inevitable, says Daniel J. Snyder, a former American hospital executive who is now in charge of all health-care services at the Parkway Holdings hospital chain in Singapore. â€œWhat will have to happen is that the cost of delivering health care in the U.S. will have to come down,â€? he said. Health care costs less in Asia chiefly because people earn less, Snyder said. â€œPhysicians per capita make less money than they do in the United States. Nurses make less money. The cost of living is less.â€? Malpractice insurance and the absence of a national health-care system also add to U.S. costs, he said.
LARGE BUSINESSES and health insurers looking for lower-cost health care are watching the medical tourism trend with interest. But, says Mohit M. Ghose, spokesman for Americaâ€™s Health Insurance Plans, the national trade group for health insurers: â€œWhat you have not seen is a rush by our sector to jump on board.â€?
He said insurers are worried about â€œlegal and quality issues,â€? particularly who is responsible for patientsâ€™ care upon their return. Patients often cannot collect compensation if they are injured. So who will pay for the care at home if there are complications?
Ghose thinks the global competition will further boost a trend already under way in the United States â€” to develop â€œcenters of excellenceâ€? that do many procedures, provide consumers information on how well they perform and compete on the basis of quality.
Ghose says he knows of only one health insurer that has gone as far as offering an overseas option to subscribers: BlueCross BlueShield of South Carolina.
In February, David Boucher, South Carolina BlueCrossâ€™ assistant vice president of health care, founded Companion Global Healthcare, a medical tourism agency that has a relationship with the Bumrungrad International Hospital in Bangkok. To address concerns about follow-up care, Companion contracted with a large network of South Carolina doctors to take care of patients when they return from overseas treatment.
â€œWeâ€™re not contemplating mandating care abroad,â€? Boucher stresses. â€œThis is an option â€” we just want to help them make it a little bit easier.â€?
So far, South Carolina BlueCrossâ€™ offer to pay for medical care overseas has attracted lots of media attention and inquiries from other insurance companies â€” but no patients.