Is medical tourism a dire threat to American surgeons?

In an earlier post, DrRich offered several potential strategies for doctors and patients to consider should healthcare reformers ultimately succeed in their efforts to make it illegal for Americans to seek medical care outside the auspices of Obamacare. To those readers who persist in thinking that DrRich is particularly paranoid in worrying about such a thing, he refers you to his prior work carefully documenting the efforts the Central Authority has already made in limiting the prerogatives of individual Americans within the healthcare system, and reminds you that in any society where social justice is the overriding concern, individual prerogatives such as these must be criminalized. Indeed, whether individuals will retain the right to spend their own money on their own healthcare is ultimately the real battle. The outcome of this battle will determine much more than merely what kind of healthcare system we will end up with.

DrRich, despite his paranoia on the matter, is a long-term optimist, and believes that the American spirit will ultimately prevail. So, to advance this happy result DrRich (in the previously mentioned post) graciously offered several creative options that could be employed to establish a useful Black Market in healthcare, which will allow individuals to exercise their healthcare-autonomy against the day when such autonomy again becomes legal. His suggestions included offshore, state-of-the-art medical centers on old aircraft carriers; combination Casino/Hospitals on the sovereign soil of Native American reservations; and cutting-edge medical centers just south of the border (which would have the the added benefit of encouraging our government to finally close the borders to illegal crossings once and for all).

As entertaining as it might be to imagine such solutions, a readily available, though much more mundane, option exists today, which is to say, medical tourism.

Medical tourism is where one travels outside one’s own country in order to obtain medical care elsewhere. It is becoming a booming business. A number of superb state-of-the-art medical centers expressly aimed at attracting medical tourists have been established in the Middle East, Singapore, India, China and elsewhere in Asia. These institutions cater to citizens of the world whose own healthcare systems cannot (or will not) provide in a timely fashion (or at all) the level of care patients may desire. Many of these institutions offer modern hospitals, numerous amenities, luxurious accommodations, attentive nursing care, and top-notch doctors – and they do it all for a tiny fraction of what the same care might cost (if you can even find it) in the U.S. and other “first world” nations.

Obviously, medical tourism is not particularly feasible for medical emergencies such as heart attack or stroke, or for chronic illnesses such as diabetes, congestive heart failure, or Parkinson’s disease, which require frequent visits and long-term management.  What is feasible is to become a medical tourist for those one-time medical services that can be scheduled and planned, for which there is a long waiting period at home, or which is simply too expensive in one’s own country. Such medical services often include coronary artery bypass surgery, hip replacements, knee replacements, and numerous minimally-invasive and not-so-minimally-invasive surgical procedures. In other words, medical tourism to a large extent is something one does for elective (i.e., non-emergency) surgery.

These are the very procedures, as DrRich has pointed out, which are now being covertly rationed in the U.S. thanks to the “never events” policy adopted by CMS and private insurers. As a result, certain categories of individuals may soon find it more difficult to obtain elective surgical services than they might have just a few years ago, and medical tourism may accordingly become a more compelling alternative.

It ought not be a surprise, therefore, that the first organization of American physicians to issue a formal policy statement regarding medical tourism is the American College of Surgeons.

The reaction of American surgeons to medical tourism ought to be obvious. They hate it. Elective surgical procedures – the very procedures for which Americans become tourists – are the bread and butter of most surgical specialties. It pains them to think of their prospective patients going off to Singapore for their lucrative bypass surgeries. American cardiac surgeons, for instance (already underemployed, thanks to American cardiologists throwing stents at every tiny coronary artery indentation they they can justify as a “blockage”), are nearly apoplectic at the idea.

It’s always a delight to read formal policy statements which attempt to disguise an entirely self-serving message as a selfless public gesture. The actual message of the surgeon’s policy statement, of course, is, “We hate medical tourism, and if you do it we’ll hate you,” but they say so on a manner which is designed to be polite, politically correct, non-judgmental, helpful and even friendly.

The surgeons in general have made a good effort, as you can see if you’d like to read the policy statement for yourself. It’s pretty much what you would expect – “Go ahead and have your knee replaced in Timbuktu if you want to. It’s your right, so go ahead and devil take the hindmost. Just don’t come crying to me when things go south a month later.”  They do so, however, in an extraordinarily collegial way.

The artful style of their policy statement aside, DrRich is struck by two aspects of the actual substance of the document.

First, the surgeons begin with a litany of dire warnings regarding all the medical considerations one must take into account before trusting one’s health to foreign medical hands:

“Some of the intangible risks include variability in the training of medical and allied health professionals; differences in the standards to which medical institutions are held; potential difficulties associated with treatment far from family and friends; differences in transparency surrounding patient discussions; the approach to interpretation of test results; the accuracy and completeness of medical records; the lack of support networks, should longer-term care be needed; the lack of opportunity for follow-up care by treating physicians and surgeons; and the exposure to endemic diseases prevalent in certain countries. Language and cultural barriers may impair communication with physicians and other caregivers.”

Obviously, these are all very important considerations. What strikes DrRich, however, is that these are the very same considerations (even the warning about endemic diseases, when one considers the MRSA infections which are secretly “endemic” in some American hospitals) which patients must also take into account before agreeing to receive care in any American institution. It may turn out that these considerations are more an issue in top-notch foreign hospitals than in your average American hospital, but DrRich is not convinced this is the case, and the surgeons do not provide any evidence that it is. In other words, DrRich sees this very good advice as being equally applicable whether one is considering becoming a medical tourist, or just a typical American patient.

Second, and more astonishingly, DrRich notes – not so much with interest, but more with awe – that the surgeons are beseeching their patients to consider just how difficult it might be to launch a malpractice suit against foreign doctors. (DrRich himself does not know how difficult this would be. Given that we are being so strongly urged these days to merge the American legal system with several varieties of international law, it might not be such a big problem.) Indeed, a careful reading of this policy statement reveals that the potential difficulty in suing foreign doctors is offered as the chief differentiator, and thus it has become the primary argument in favor of good-old-American-surgery. The surgeons, in essence, are saying, “Let us do your surgery, because we’re easier to sue if we screw up.”

This, from the very body of American physicians who are most at risk for malpractice suits, and who traditionally have been most vociferous in favor of malpractice reform.

DrRich can only shake his head in wonderment. If medical tourism is viewed by surgeons as such a dire threat that they have embraced, as their chief weapon against it, a celebration of the ease of suing American doctors, why, one can only conclude that medical tourism must have caught on far more than most of us realize.

As an American physician who has always been proud of American medicine, DrRich’s innate tendency is to lament the fact that Americans are finding it to their advantage to travel to Mumbai for their hip replacements. But as a patriot, he celebrates the fact that his fellow citizens are willing to go to such lengths to exercise their individual autonomy. He finds it a hopeful sign.

Our would-be oppressors might find it more difficult to hold us down than they may think.

Richard Fogoros is a cardiologist who blogs at The Covert Rationing Blog.  He is the author of Fixing American Healthcare – Wonkonians, Gekkonians, and the Grand Unification Theory of Healthcare.

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  • JenniferL

    Don’t put anything past the democrats.  They gave themselves vast extra-Constitutional powers in ObamaCare to do whatever the heck they wanted.

    ObamaCare contains Fiat Power to make up any regulation they want.

    • Brian Curry

      [Citation Needed]

  • Rob Oliver

    So who exactly is to manage complications of these procedures? Do you expect an American cardiac surgeon or orthopedist  to assume low reimbursing and difficult care for a post CABG sternal wound or total joint performed because someone wants to save $1000 by going to Thailand? The post operative care and complications from these complex procedures does not lendthemselves to just exporting it across borders.

  • russ

    One of 10 USA workers get part-paid by OweBama and his ilk, in USA health care.

    Restrain medical-cost increases? Sure — right after pigs fly. And Chubby Mike Moore actually reads books with facts in them. And the MD-lot isn’t filled with Lexuses.

    Gimme a break.

  • Amit Bhagat

    Dear Mr Richard,

    I Agree with you totally. A Heart Bypass Surgery in U.S costs around $1,30,000 but the same costs only $7000-$10,000 in India i.e One tenth . So its very clear that people staying in U.S. will opt for Medical Tourism. This aspect becomes more active in case of those who are not insured in U.S. as it becomes impossible to bear the huge cost of life supporting surgeries.

    Apart from Coronary artery bypass surgery, hip replacement, knee replacement more specialized Treatments like Dental, Cosmetic, IVF surgeries are also getting the attention from people from U.S, U.K. and other first world countries.

    This clears the point that Why American Surgeons are worrying ….

  • Anonymous

    Market forces slip through the gripping fingers of the most determined governments.

    In spite of the monstrous, awkward, bumbling, enormously expensive efforts of the government to control cost, market forces slip through and do a better job.

    Rather than abdicate control to third party payers, vesting stewardship in them with onerous results, why not allow market forces to re-enter the medical arena?  Use insurance to do that for which it was originally designed … to mitigate against financial ruin.  Insurance was not born to cover a thousand sundry entitlement expenses.

    Use a solid public health clinic system as the safety net.

  • Molly Ciliberti

    I’m more worried about the drug resistant organisms that they will pick up abroad including in the hospitals.

  • Terence Ivfmd Lee

    Bear in mind that traveling abroad for medical care can go both ways. Some American infertility patients go abroad for their care. Likewise, some infertility patients come from other countries to the US for their care. Competition is always good for the interests of the consumer/patient, while monopoly is always good for the interests of the provider.

  • Expat Doctor Mom

    Oh Dr. Rich, you humor me in a good way. I love the way you write.

    So many points you bring up. I too am an American who has been proud of American Medicine. I preface this as I don’t want one to misinterpret my next statement: If Obama care ever makes it illegal for me to choose to go outside of the USA then that will be the day I either protest or relinquesh my citizenship.  I have access to 3 others… But this would be a sad day.

    Living 5 1/2 of the past 6 1/2 years as an expatriate and also having practiced abroad (as the “Trailing Spouse… not by choice!), there are plenty of places that provide equivalent care to the USA.  I have the oppurtunity to review reports from executive physicals from Bumrungrad hospital in Bangkok and they read like an extremely thorough physical out of Mayo.  You can add Thailand to your list in Asia. Lots of nice looking cosmetic work coming out of their hospitals, not that I have personally experienced!

    In regard to “should American surgeons then be responsible for handling post op complications from these medical tourism cases”, I would hope they would with the understanding that they would not be liable for any morbidity/mortality from the initial botched job.  However, I have always felt I respect a physician more if they do not do what they are not comfortable with.  So if they elected not to take on said case then that is their perogative.

    As to suing doctors abroad.  It is almost a non issue in Qatar.  Liability cases are limited to $40,000 USD per case.  I cannot speak to other countries rules.

    On you website: you should have your links open in new windows and it would be fab to follow you by RSS or email. I don’t see this as an option.


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