Medical Tourism ? Or Globalisation of Healthcare !

Indian President Off to U.S. AP Published: October 1, 1982

“President Zail Singh left here today for the United States where he will undergo a heart examination and possible surgery at the Texas Heart Institute in Houston”.

American Doctor gets a new hip at Mumbai hospital – Patients’s Experiences on a hospital website May, 2006

“I'm working full-time in a physically demanding job and my wife says she's never seen me happier. I run three miles every morning and say a little prayer for you, Pradeep and Dr Malhan and all of your wonderful staff while I run. You have truly given me my life back.

The only problem I have is occasional pain in the other hip. Hip resurfacing is now available at a nearby hospital but I'd prefer to have your team do it--even though it means paying out of pocket.

I hope this finds you all healthy and prosperous.”

Dr Jim Allen. Plymouth, MN, USA
(Seven months after returning to his home in USA after a Hip Surgery in India.)

These two news items are symbolic of the transformation that has taken place in just about the past two decades in the Indian healthcare sector ; particularly in the high end tertiary care segment. This has been made possible within such a short span of time due to the pioneering efforts of some of the top private hospital groups in India, like Apollo, Wockhardt Hospitals, etc. Today the top private hospitals in India not only have the best in class medical infrastructure and technology like 64 Slice CT Scans, Computer Navigated Surgery Suites, etc., they also have on board physicians and surgeons who are amongst the best in the world. There is a reverse brain drain happening now, with more and more top doctors of Indian origin returning back to India and delivering world class services at Indian hospitals.

INDIAN MEDICAL FRONTRUNNERS: MEETING INTERNATIONAL BENCHMARKS

The Joint Commission on Accreditation of Healthcare Organizations
(“JCAHO”), an organization that inspects hospitals, now has an international arm called JCI that audits and accredits foreign medical centers to see if they meet high American
standards. The hospitals belonging to the Wockhardt and Apollo group have received the JCI accreditation that confirms that these hospitals adhere to international standards of clinical care, safety of environment, medication safety, respect for rights and privacy, international infection control standards and access to dedicated, well trained staff.

Standards of care and level of medical expertise in top hospitals in India are generally just as high as and sometimes even higher than at home in the industrialized wealthy countries. The work culture in Asia is very persevering and countries are warm, both climate wise as well as hospitality wise. As the New York Times columnist Thomas Friedman noted in his authoritative book “ The World is Flat” , “France can forget about trying to save her 6 week worker vacation period standard holidays. In India they are trying to figure out how they can work 24 hours a day.”.

No wonder international patients are delighted with Indian hospitals. The Wockhardt Hospitals group has a page on its website that has over 30 video testimonials of American and British patients extolling them for the services experienced by them.

THE REVERSE INFLUX: REASONS

India has traditionally been always a destination for patients from the neighbouring countries like Nepal, Bangladesh, Afghanistan and Sri Lanka. In the eighties. patients from the Middle East began coming to hospitals in major Indian metros. A large number of patients come to private hospitals in India from countries in East Africa like Tanzania, Kenya, Uganda and in the West Africa like Nigeria , where the facilities for advanced medical care just do not exist .

But this recent phenomenon-- which has emerged over the last couple of years--of patients from the developed world, i.e, from USA, Canada and UK coming to India for high end surgical care is an interesting one and the primary subject of this article. In fact, this new wave of patients coming to India from the West for highly sophisticated surgeries like Hip Resurfacing , Cardiac and Spinal Surgeries may become another driver of strengthening India’s march towards becoming a global economic leader following its success in the field of Information Technology and Biotechnology.

United Kingdom and Canada have socialized medicine where the public exchequer bears the cost of the healthcare for the whole population but the system is under strain and the citizens have to wait and bear the pain for months. In some instances , the waiting period could be as much as a year to get a surgery done. Many of these patients are now taking their own decisions to fly to another country and get the procedure done and pay out of their own pockets.

THE COST DISADVANTAGE:

The situation in America is quite different, and, in fact, pretty serious. According to the Economic Research Initiative on the Uninsured, conducted by the University of Michigan, 20 percent of Americans between the ages of 19 and 64 — 36.5 million adults — have no health insurance. Nine percent of children under 19 are uninsured, bringing the total to 45.5 million uninsured Americans, or 17.8% of the non-elderly population.

These statistics don’t include the underinsured, such as people who pay a lower premium for policies with larger deductibles and co-pays. So the likely number of people uninsured or under insured and those left to fend for themselves is estimated to be over 65 million. Health insurance policies -- with high deductibles, co-pays, and many exclusions -- offer little protection during a serious illness.

The cost of surgery at a private hospital in the United States is very expensive due to various reasons like the general high cost and scarcity of skilled medical manpower, cost of litigation that forces the hospitals and physicians to buy expensive indemnity cover and its impact on the whole practice of medicine. As a result, the medical practice has become mired in documentation and procedures, and physicians are compelled to resort to defensive medicine and over consumption to avoid litigation, inflating the costs further.

Illness and medical bills caused half of the 1,458,000 personal bankruptcies in 2001, according to a study published by the Journal of Health Affairs. The research was carried out jointly by researchers at Harvard Law School and Harvard Medical School, Dr. David Himmelstein, the lead author of the study and an Associate Professor of Medicine at Harvard comments: "Unless you're Bill Gates you're just one serious illness away from bankruptcy. Most of the medically bankrupt were average Americans who happened to get sick."

The result is that thousands of American citizens are now increasingly traveling to countries like, India, Thailand, Costa Rica and Mexico for surgical care. Often these are desperate patients for whom the choice is either to mortgage their property and pay for the much needed surgery or take a leap of faith and travel to another country for surgery. The United States Senate Special Committee on Ageing held hearings on the issue of medical tourism in June 2006 and called for a task force of experts to explore the impact and safety of lower cost healthcare abroad.

Health insurance has been a major plank on which the elections are being fought in the USA, currently. Electoral promises of revamping the health insurance sector and restoring it to a semblance of normalcy have been flying thick and fast, but it remains to be seen how many of these commitments made in a pre electoral, myopic context will actually translate into policy changes—rather, how much of it would be possible.

That medical tourism is a reality and will continue to be so is not even arguable. But it’s necessary for all stakeholders to look at the developments from a pragmatic perspective so that expectations are realistic. This is all the more necessary because medical tourism is already mired in many myths, many of which can be detrimental to the healthy growth of the sector. Discussed below are five such myths that have been projecting a distorted picture of medical tourism and the expectations associated with it:

SEARCHING FOR SOLUTIONS:

Many of the big corporate groups, particularly the automobile companies in Michigan, have a mounting healthcare cost burden that seems to be threatening their survival. In an effort to reduce the financial burden of employee healthcare, several Fortune 500 corporations are evaluating the feasibility of outsourcing expensive medical procedures to offshore healthcare destinations.

The insurance industry is looking at becoming an active participant in medical tourism. Top insurance groups like Blue Cross Blue Shield, Aetna and CIGNA etc. are exploring the opportunity to sell insurance policies that will enable or encourage patients to have expensive surgical procedures in India.

The outsourcing of healthcare services to hospitals outside the USA is therefore inevitable and considering that the present size of US healthcare is 2 trillion dollars which is expected to triple in next 10 years, even a fraction of the surgical work outsourced would mean a tremendous opportunity for high quality providers in Asia.
In view of the above, there is a tremendous opportunity for India to position itself as a destination for high quality and good value healthcare destination. Other countries in Asia like Thailand, Singapore and Malaysia are getting organized and would certainly provide tough competition. These countries, though cost wise slightly more expensive than India, have an advantage of being popular tourism destinations with good external infrastructure.

Medical Tourism is expected to be a $40 billion industry by 2010 [1] . Globalisation will mean more choices and flatter terrain for patients across the world and they will go to wherever they find better service, better quality of clinical outcomes and better monetary value. While the Indian government would have to take a number of initiatives to improve our infrastructure, air connectivity and liberalize the visa regime, the providers i.e. the top hospitals need to work together to build a strong positioning for Indian healthcare. There are a myriad variety of issues to be addressed by us together like finding ways to ensure continuity of care to the foreign patient after his return home, preparing for legal liabilities, ensuring uniformity of pricing and presentation of medical treatment packages, and, above all, ensuring that all our actions keep the Indian Healthcare brand flying high.


[1] Open-Heart Surgery--90% off - Forbes.com http://members.forbes.com/forbes/2007/0813/021.html

Five Myths about Medical Tourism

MYTH 1. It is MEDICAL TOURISM

While the term Medical Tourism has become really popular and is one of the most frequently searched terms on top search engines like Google and Yahoo by the people who are exploring cost effective options for overseas treatment , the word ‘TOURISM’ per se is the last thing on the mind of most of the patients. Let us understand that the decision to travel abroad for serious medical treatment or surgery is not an easy one and the patients considering doing so are highly anxious and unsure. To see the Taj Mahal or laze around on a beach at Goa, is the last thing on their minds. They just want to have a good medical outcome and return home safely. They could always have a real holiday later with the money saved on medical treatment in this trip, when they recover, at a destination of their choice.

A general survey of the overseas patients coming to Indian Hospitals indicates that less than 2 percent of them actually went on a vacation post- hospitalization. This is also because the majority of patients presently choosing to come to India are those who get high end surgeries like Hip or Knee Replacement, Spinal or Cardiac surgery done. And these procedures do not permit any high impact activity during the recovery period after the hospitalization period. Even in case of a cosmetic surgery, the surgeon is most likely to advise the patient - "no sun, no sea, no sand".

So Medical Value Travel is probably a better expression than Medical Tourism – but it seems we cannot really get away from the informal online marketing rules of the new Googleised world

MYTH 2. Cost Arbitrage is the only reason for overseas medical travel

The majority of the patients coming from developed countries like, US, UK and Canada to the top corporate hospitals in India are now coming here for very advanced surgical procedures. Most of the doctors at these hospitals have worked for many years at the best institutions in the West and have been continuing their high quality of innovation, research and developmental work at Indian hospitals. They also happen to improvise their skills much more than doctors in the developed world, just because they have to treat a very large number of local patients. Let us take the example of a few procedures being done routinely at Indian Hospitals like Off Pump Beating Heart Cardiac Surgery - the quality and skill with which such procedures are performed at good hospitals in India is far ahead of the volume of similar work in the developed world. Most of the top hospitals in India are equipped with the best in class of medical technology and latest equipment like 64 slice CT scan, Computer Navigated surgery and digital cath labs, while many of the hospitals in the developed world are still using equipment which is at least a generation older. And so, hospitals in India are able to offer outcomes backed by best in class clinical skills and contemporary technology at a fraction of the cost in the West.

In a world that is getting more and more transparent and flatter-- thanks to the growing popularity of the internet search-- patients who have anyway decided to take their healthcare in their hands and are going to pay for it on their own, are soon able to appreciate the value offered to them by world class hospitals in India. So it’s not about cost arbitrage but truly about the globalization of healthcare. In a globalized world, the consumers will inevitably move to where they get best value.

MYTH 3. Medical Tourism - It's a new, sunrise and booming business to enter for everyone

Surely this business is growing and seems to attract a number of people from across various sectors. Professionals particularly from the Tourism sector are looking at setting up facilitation companies. But this business is not an easy one and quite different from the travel and tourism business. Let us not forget that in this business we are primarily dealing with the health and safety of the patients and they are extremely anxious and worried about planning their overseas trip for medical treatment. While the doctors and the hospitals do have competent skills and capability to deliver the service, the challenge is really during the pre and post hospitalization phase. So the facilitating companies have a great responsibility to handle the queries of the patients carefully and must have medical personnel on board who can understand and coordinate the exchange of medical opinion and queries with the experts at the hospital. Even after the patient returns home after treatment abroad, he may still need some support and the hospitals and facilitators must provide the information required promptly. Medical and surgical packages can not and should not be sold like travel and tourism packages as every patient’s medical condition is unique and he should be able to be dealt with by trained personnel.

MYTH 4. Overseas medical treatment is the best option for any kind of healthcare need

Certainly not. Traveling abroad for tertiary care is beneficial only for some procedures. The first prerequisite is that it is, first of all, safe to travel a long distance with that condition. Generally orthopedic, spinal surgeries and other procedures that involve cold elective surgeries that can be postponed or planned to be delayed for a while are suited for traveling and being performed abroad. These kind of procedures also generally do not require much of post operative care after the patient’s return home. Also, the patient must get a good cost benefit. Since the return airline fare itself is a significant add on expense usually costing USD 1500 to 4000 – any surgery that can be done in the patient’s home country for less than USD 6000 is ideal for local treatment and prolonged travel should be avoided. Also, very chronic and acute illnesses requiring long treatment that need to be moderated frequently, for example, cancer etc. are not really suited for overseas care.

MYTH 5. Medical Tourists will make the healthcare access difficult for local patients in India

Sounds logical, but it isn’t, considering the fact that the bulk of Indian patients will always use value for money sharing and single room beds, while the premium rooms and suites in Indian hospitals can be used by foreigners which are priced higher. Even if this business grows exponentially, it will never be a major portion of the private healthcare business in India. The sheer volume of local patients and the demand for private hospitals driven by expanding insurance coverage and rising middle class incomes is fuelling the setting up of dozens of new hospitals, even health cities in all major Indian cities. The better utilization of premium end hospital facilities by foreign patients will help the hospitals utilize their capacities better and invest in new modern equipment because they must become world class to sustain their international business. India has no dearth of human talent, enterprise and a strong local pharmaceutical and hardware industry , so India can and will expand its healthcare facilities to meet the growing local demand and generate employment. Eventually the market forces shall come in to play as has happened in other sector like telecom where the market forces once unleashed have made it possible for a common man today to have a mobile phone in his pocket and India today has the cheapest call rates in the world.

Medical Tourism to India, All Expenses Paid

US NEWS & WORLD REPORT Avery Comarow

Lots of talk, not much action—until now. In January, Serigraph Inc., a West Bend, Wis., manufacturer, will become the first U.S. company of any size to embrace medical travel or medical tourism, offering employees the option of having certain nonemergency operations, such as joint replacement, in India. The company will pay all expenses, including travel and lodging for a companion. The incentive for employees is that they don't have to pay a deductible—typically $1,000 to $5,000—or the hospital copay, which would be 10 percent to 20 percent of the charges.

Last May, I went to India and Singapore to explore the trend of growing numbers of under- and uninsured Americans heading to both places and other foreign climes to take advantage of package prices for hip replacement, heart valve repair, spinal surgery, and other elective procedures that can be 80 percent less than the sums charged by U.S. hospitals. To cite one expensive example, heart bypass surgery can easily run up a $70,000 to $133,000 bill at a U.S. center, compared with an average of $7,000 at Indian hospitals catering to westerners. An uninsured patient I interviewed extensively in India paid a total of about $25,000 to have both hips and one knee replaced, including airfare and incidentals. He easily could have paid more than $125,000 at a U.S. hospital. And there are plenty of similar cases of huge price differences.
Perhaps 50,000 Americans currently go abroad for that kind of surgery. Hundreds of thousands of others go as actual medical tourists, combining cosmetic plastic surgery, extensive dental work, and other treatments with time spent sightseeing and lying on the beach in fun destinations like Mexico and Costa Rica.

Until now, however, the movement has largely been fueled by patients paying out of pocket. Health insurers and corporations have stayed on the sidelines, talking endlessly about whether to get involved and, if so, how. There's reason to be cautious. How can the quality of care abroad be guaranteed? What if an employee has a surgical complication after coming home?
But the potential savings for employers are too large to be ignored forever, and Serigraph, which has about 1,200 employees worldwide and slightly fewer than 1,000 in the United States, is taking the plunge. The pilot program will be administered by Anthem Blue Cross and Blue Shield of Wisconsin, an affiliate of WellPoint, the largest U.S. health insurer in numbers of members (and the originator of the Serigraph initiative). Employees needing the following procedures will be covered:

Hip replacement or resurfacing
Knee replacement
Heart bypass surgery
Heart valve repair or replacement
Spinal fusion
Prostate surgery

Employees will be treated at two Apollo Group hospitals, in Bangalore and New Delhi, both accredited by the Joint Commission International. An Anthem case manager will steer patients through the process, including managing medical complications should they occur.
Finally, a corporate pioneer. The Serigraph move will get a lot of attention. I'll be watching, and WellPoint, of course, will as well. "One reason we're doing this is to understand the extent that employees will choose this option," Lisa Latts, WellPoint vice president for programs in clinical excellence, told me. "They will do their own risk-benefit analysis."

General Motors and Starbucks spend more on healthcare than on buying steel or coffee.

Just as I was done with reading a news report from Associated Press - "Obama hopes to avoid Clinton health care missteps" (reproduced below) - which mentioned the sensational fact that GM spends more on healthcare than on buying steel for manufacturing cars, One of our top surgeons forwarded me this rather emotional message from a recent US patient who came to Apollo Hospitals for Hip Surgery. She could not afford to get the surgery done at a local private hospital in US and decided to fly to India to save almost 45000 US dollars. The remarkable thing is that she decided to come to Apollo Hospitals for its exceptional clinical success rates, superior technology at a fraction of US cost but was overwhelmed with India's centuries-old traditions of Eastern care and warmth. "Vasudhaiv Kutumbakkam" as our 5000 year old scriptures taught us to believe - the world is our extended family.
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Obama hopes to avoid Clinton health care missteps

12/6/2008, 10:36 a.m. EST
By KEVIN FREKING
The Associated Press

WASHINGTON (AP) — President-elect Barack Obama and his aides are determined not to repeat the mistakes the Clinton administration made 15 years ago in trying to revamp the nation's health care system. That means applying some of the lessons learned — moving fast, seizing momentum and not letting it go.

Tom Daschle, Obama's point man on the issue, discussed the early strategy, although details of Obama's proposals won't be finalized for a while Already, however, the political and public relations parts are coming into place..

The strategy begins with giving people the chance to highlight their concerns and experiences. Daschle invited people around the nation to hold what amounts to house parties from Dec. 15-31. Obama's transition team will gather the information from those meetings and post the material on its Web site, Change.gov: The Obama-Biden Transition Team.

Daschle did not provide any details about how the incoming administration would pay for expanding coverage. Instead, he made the case that not dealing with health care would worsen the economic problems because companies such as General Motors spend more on health care than steel and Starbucks spent more on health care than on coffee.
"Health care is going to destroy many of our manufacturing industries unless we fix the system," he said.

He outlined an array of problems with the current system: high costs, lack of access and mediocre quality. He said the myth has long been that the U.S. had the best health care system in the world, but statistics and an increase in medical tourism show that is not the case.