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Overseas, Under the Knife
June 10, 2009
The New York Times
By ARNOLD MILSTEIN,
MARK D. SMITH
and JEROME P. KASSIRER
ONE consequence of the high cost of medical care in the United States has
been the rise of medical tourism. Every year, thousands of Americans undergo
surgery in other countries because the allure of good care at half the price is
too good to pass up.
Average total fees at well-regarded hospitals like Apollo and Wockhardt in India
are 60 percent to 90 percent lower than those of the average American hospital,
according to a 2007 study by the consulting group Mercer Health and Benefits
(where Dr. Milstein is affiliated). Even compared with low-cost American
hospitals, the offshore fees are 20 percent to 50 percent lower.
Most medical travelers seek cosmetic procedures like facelifts and liposuction,
but an increasing number have high-risk operations like heart surgery and joint
replacement in places like India, Singapore and Thailand.
Is this a good idea? The only way to know is to find out how foreign hospitals
and surgeons compare with their American counterparts.
Which Americans consider this option? Typically, they are people who have either
no health insurance or meager coverage. Though not poor enough to qualify for
Medicaid, they cannot afford a good health plan. But lately, even some people
with good coverage have been encouraged to take advantage of cost savings
A few pioneering American insurers like Blue Cross Blue Shield of South Carolina
and self-insured employers like the Hannaford Brothers supermarket chain sent
American doctors to evaluate foreign hospitals. Favorably impressed, they now
offer payment for travel expenses and cash incentives as high as $10,000 for
choosing offshore hospitals.
For very costly operations like open heart surgery or hip joint replacement,
savings far exceed these payments. That is not to say that offshore surgery
could substantially lower health care costs. Less than 2 percent of spending by
American health insurers goes to the kind of non-urgent procedures that
Americans seek overseas.
Other negatives are obvious: people having surgery done halfway around the world
are far from their regular doctors as well as friends and family. Consider,
also, what happens if an American abroad falls victim to negligent care.
Arranging transfer to another hospital may be difficult — and malpractice suits
typically face longer odds and smaller payments than in the United Sates. To
mitigate these problems, some insurers and free-standing medical travel services
offer coordination with American doctors, local concierge services and
supplementary medical malpractice insurance.
There is reason to think the quality of care at some foreign hospitals may be
comparable to quality in the United States. More than 200 offshore hospitals
have been accredited by the Joint Commission International, an arm of the
organization that accredits American hospitals. Many employ English-speaking
surgeons who trained at Western medical schools and teaching hospitals.
So should offshore surgery be welcomed as a modest way to make American health
care more affordable? We can’t know until we can directly compare the outcomes
with those of American surgery. To begin, we must adopt a uniform way for
American hospitals and surgeons to report on the frequency of short-term
Medicare could do this by requiring that all participating hospitals and
surgeons count pre-surgical risk factors and post-surgical complications during
hospitalization and for 30 days afterward, when most short-term problems become
evident. The system used for many years by Veterans Affairs hospitals to reduce
surgical complications is the best option for this, since it is available to all
American doctors through the American College of Surgeons. So far, however, only
a small minority of surgeons participate in this or any other valid national
system of reporting surgical outcomes.
Patients and their surgeons also need comparable measurements of long-term
success. Medicare should lead by adopting Sweden’s method of monitoring hip
joint replacement outcomes. It tracks, for example, a patient’s ability to walk
without pain six years after surgery.
Finally, Medicare should invite accredited offshore hospitals and their
affiliated doctors to participate in all of its comparative performance
reporting systems. Beyond informing Americans contemplating treatment abroad,
such comparisons would allow us to learn if our care is the world’s best — and
to accelerate our improvement efforts if it is not.
Arnold Milstein is a doctor specializing
in health care improvement.
Smith is an internist
and the chief executive of a health care foundation.
Jerome P. Kassirer is a professor
at Tufts University School of Medicine.
Overseas, Under the Knife,
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