Under The Knife In Bangalore

If he could have, Brad Barnum would have kissed the ground when he climbed out of the car in Ruidoso, N.M., at the end of March. But the 53-year-old building contractor had undergone major remodeling himself--and his new knee and two new hips ruled out kneeling for a few more weeks. Still, he was ecstatic. More than two months after leaving for the hospital, he was home, and he had afforded the otherwise unaffordable. By having the work done in India, at Wockhardt Hospital in Bangalore, he'd gotten his new joints for just $23,000. Even after adding about $5,000 for airfare, passport, visa, and incidentals, the total was nearly 80 percent less than the $125,000 or more he easily could have been charged by a U.S. hospital. And that bill wouldn't have included physician fees and "ancillary charges."

Barnum is one of thousands of Americans--estimates range from an ultraconservative 5,000 to 500,000 annually if minor procedures are counted--who are leaving the States for surgery when they have to come up with funds themselves. They may be self-employed or work for a small business and lack health insurance, for example, or their procedure may not be covered. More than 1 in 4 workers earning at least $60,000 a year went without insurance in 2006, according to a Census Bureau survey; too well-off to be eligible for medical assistance, they can often wring tens of thousands of dollars out of hospital "rack rates" by going abroad. Some employers and big insurers like UnitedHealth and Blue Cross and Blue Shield are so intrigued by "medical tourism" that they're beginning to sniff for signs that it might be smart to cover it. "I was totally amazed not just at the quality of the medical care but at the quality of the service," says David Boucher, an assistant vice president of healthcare services at BlueCross BlueShield of South Carolina who has visited many facilities abroad. "The initial driver may be price, but patients' positive experiences will do a lot to advance the movement."

So far, there's been mostly talk, with little action from employers and health carriers. In fact, the first verified case of major surgery abroad as an employee benefit took place only earlier this year. (The patient reportedly paid nothing out of pocket for a knee replacement--in fact, the company, a North Carolina manufacturer, paid him a tidy sum for saving so much money.) Wockhardt, where the procedure was done, won't name the company.

Meanwhile, patients are finding their way abroad on their own. Wockhardt's hospitals in Bangalore and Bombay operated on about 850 U.S. patients in 2007, more than double the 2006 total. In Thailand, Bangkok's Bumrungrad Hospital says it treats more than 38,000 Americans a year--a somewhat inflated figure that represents "patient encounters," not individual patients, and includes expatriates. Other hospitals in India and Thailand, as well as centers in Singapore, are actively courting Americans, and the governments of South Korea and Taiwan are about to launch campaigns.

Low-budget dentistry, Botoxing, lipo, and other cosmetic work have for years drawn Americans into Mexico and to other Latin American countries (box, Page 48). But the growth in serious elective surgery halfway around the world is new. Josef Woodman, who publishes the Patients Beyond Borders series of guidebooks to finding good care (www.patientsbeyondborders.com), thinks about 50,000 patients a year leave the country for major noncosmetic elective procedures such as joint replacement, coronary artery bypass, new or repaired heart valves, or back repair.

Many, like Barnum, do the legwork on their own. But concierge services like MedRetreat.com and IndUShealth.com are multiplying, to help with lists of potential hospitals, appointment scheduling, arranging airport pickup and drop-off, and general hand-holding. (Information from Woodman's annual hospital survey has been incorporated into the World Hosptal Finder at health.usnews.com/worldhospitalsearch, a U.S. News search tool for people who are seeking care abroad.)

Large insurers and employers are watching with interest--and skepticism--to see what happens as demand grows. "It's very nice to say that India, to take one example, can handle Americans, but there are only three to five hospitals there" with enough capacity to absorb a surge, says Ori Karev, CEO of UnitedHealth Group International, an arm of UnitedHealth that offers health consulting services to companies abroad. Moreover, he wonders, can high quality be sustained "with hundreds of thousands of patients traveling for care? I have my doubts." Then there are fundamental questions of safety and postoperative care back home. "Say I get treated overseas and something goes wrong," says Karev. "Who do I sue? Where do I sue? Who owns that hot potato of accountability--my insurer? My employer?"

The questions are just as relevant to solo travelers. Woodman tells of a Vietnam veteran who had a hip replaced, developed complications on his return, and found his doctors here unwilling to help. "There's a lot more burden on the consumer to have a successful medical journey," says Woodman.

Doing the sort of advance research that makes this possible can be arduous. You might or might not get answers if you ask about a hospital's mortality rates or a surgeon's credentials and how many heart valves he has replaced, for example. "Getting data out of some of these places is like pulling teeth," says Woodman--and even if you do, the answers are not necessarily trustworthy. Not that stateside hospitals cheerfully volunteer such information. But they are being monitored by the federal and state agencies and professional and trade organizations that collect such data. "Our system is subject to extreme scrutiny, for better and for worse," says Karev. Overseas, he says, similar monitoring is largely absent. That is especially true in developing countries such as India and Thailand, which offer the least-expensive options.

So far, however, no reports of patterns of botched operations, rampant infections, or other warning signs have surfaced. In March of last year, the Singapore National Eye Center suspended laser eye surgery after 17 patients developed an inflammation, but it was the first interruption of the kind at the center. A few weeks later, surgery resumed. Overall, medical standards in Singapore, where prices are somewhat less attractive (table, Page 47) but English is universal, are very high, especially at western-oriented hospitals such as Mount Elizabeth and Gleneagles.

One precaution Americans can easily take is to choose a hospital accredited by the Joint Commission International, the global arm of the Joint Commission, which makes sure U.S. hospitals meet specific standards. In early March, as Barnum was recuperating from his two hip surgeries and faced his final procedure, Wockhardt's facility in Bangalore was recovering from a grueling JCI accreditation survey. (Accreditation was awarded in mid-April.) The hospital is immaculate but makes no attempt to look fancy; it's a Wal-Mart next to the soaring atrium and opulence that make Bangkok's Bumrungrad Hospital especially popular with medical travelers.

Accreditation does not ensure good care, but it does offer important evidence of safety; Karen Timmons, president and CEO of the JCI, says going to an accredited hospital is "essentially a risk-reduction activity." Physicians must be adequately credentialed and their patient data examined at least once a year to pick up a spike in deaths or complications, for example, or longer hospital stays. And as a patient moves through the hospital, a formal system must track him to avoid treatment mix-ups. A transfer from the OR to intensive care at Wockhardt, for example, is documented with a written transfer statement and verbal confirmation by a physician an compiled into an ongoing summary. Computerized tracking, with supermarket-type bar codes that can be scanned from patient wristbands and stickers on their records, is coming soon.

JCI standards also call for various means of minimizing infections, including collection and review of infection statistics and any necessary corrections. At Wockhardt, water used in surgery and laboratories is filtered and regularly tested. Western patients always get bottled drinking water ("for comfort," says Arshanapalai Malathi, head of medical serv-ices). Dispensers of disinfectant alcohol gel at the foot of each bed for hand cleaning are hard to miss.

A safe blood supply cannot be assumed--especially in a developing nation. "When we started watching the development of medical tourism," says Karen Lipton, CEO of the AABB, the association that represents American blood banks, "we asked ourselves, 'Where is the blood coming from? How well do they screen donors? Who's making the judgment about the safety of these products?'" Patients can and should ask a hospital representative these questions, but there is no way to verify the answers. On the other hand, says Lipton, the hospitals "don't want to do anything bad--the last thing they want is for people to go back home and have problems."

Bar-coded blood. Lipton urges patients to also ask a hospital how blood gets to the right patient. She strongly advocates a bar-coded bracelet or other wearable accessory that is scanned before a transfusion. At Wockhardt, which tracks blood in ledgers and on paper slips, there have been two near misses in which patient and blood did not match, says blood bank director Jyoti Balani. Both errors were caught in time, she says, and blood-borne infections are nonexistent. "We try to avoid transfusions," says Balani. "I can't remember any international patient in the last six months who needed blood." Banked blood comes largely from "replenishment donors"--local residents with a hospitalized relative are expected to donate. All blood is screened for HIV, hepatitis, syphilis, and malaria.

Joint-replacement patients are a special class in all hospitals because of the consequences of infection: An artificial joint that harbors a deep infection often must itself be replaced. For Barnum's operation, surgeon Sanjay Pai and his team, like those at good U.S. hospitals, sealed off their skin, even breathing filtered air pumped into hoods covering their heads. Wockhardt, like its competition, has to be persuaded to go public with its rates of postsurgical infection. Says Pradeep Thukral, head of international marketing, "Our competitors can claim that their data is better, and who can prove them wrong?" But the statistics are comparable to those of good U.S. hospitals--a 1.1 percent rate of surgical infection for heart-bypass patients, he says, and zero for joint replacements.

In Asia, nurses play a much smaller role in care than they do in U.S. hospitals. Emily Slaback, a former ICU nurse from Haslet, Texas, whose left hip and knee were replaced at Wockhardt in February, says they are more like nurse's aides. They are not expected to check patients as often or as closely, so patients have to take responsibility. Calling a doctor's attention to a bruise, for example, could prevent a bedsore that might become infected and prolong the stay. And while nurses who care for Americans are trained in English, their command is often incomplete. After his first surgery, Barnum was given a special mattress to prevent bedsores. He asked the nurses for the same mattress after his second surgery but couldn't make himself understood--or, as he says, perhaps they felt he didn't need it.

There would be no need for uninsured patients to go abroad at all, of course, if the prices they were quoted in the United States were more in line with what insurers and Medicare pay. In U.S. hospitals, the uninsured and wealthy foreigners are the major groupscharged full price for an elective procedure. (People who come in through the ER for nonelective surgery will get a list-price bill, but few hospitals expect to be fully repaid.) There should be plenty of room for price cutting--for routine heart-bypass surgery in Texas, the list price is about $70,000 at one hospital in Abilene and $47,000 at one in Austin. But commercial health plans typically pay at least 60 percent below list. And Medicare pays even less--$18,609 to $23,589 on average for an uncomplicated bypass.

Would a U.S. hospital be willing to negotiate a heavily discounted price in advance with an individual patient? "If you go in and say, 'I'm paying for it myself, I'm not covered,' " says Richard Schirmer, vice president for healthcare policy analysis at the Texas Hospital Association, "they'll give you maybe 10 or 20 percent off if you pay cash upfront for the whole thing--at most, 20 percent off the rack rate." Rick Gundling, a vice president of the Healthcare Financial Management Association, which represents hospital financial administrators, can't name a hospital willing to go further, but he sees the day drawing closer. "Hospitals should embrace the retail market," he says. " As patients start calling around to shop prices, hospitals will have to start to compete on price, and medical tourism will add a whole new level of competition."

Coming in with a concrete "let's make a deal" proposal can't hurt. "Ask to pay the Medicare reimbursement, and offer a very, very aggressive payment plan," suggests Gwynn Smith, a partner with HFS Consultants, an Oakland, Calif., group that works with healthcare organizations. "Offer to put a lot down--20 or 25 percent, more if you can--and pay it off as fast as possible." (Average Medicare payments for many common procedures are available at www.hospitalcompare.hhs.gov.) Your best shot at success, Smith says, is to get in to see the chief financial officer. Lower-level financial counselors "have no idea of the costs," she says.

In a sign of market forces at work, a handful of American hospitals have struck deals with North American Surgery, a Canadian company (www.northamericansurgery.com) formed last August to match U.S. hospitals in Kansas, Michigan, New York, Oklahoma, and Washington that are willing to provide certain procedures inexpensively with American patients who need them. Only travel and lodging are extra. Hip or knee replacement or heart-bypass surgery is $14,000; weight-loss surgery is $10,000 or $15,000. The service is free; the company is paid by the hospitals.

Agreeing to offer low prices is mostly what qualifies hospitals to make the list, says Richard Baker, the entrepreneur behind North American Surgery. He says he also makes use of HealthGrades.com, a service that gives hospitals one, three, or five stars for performance. But in the latest ratings, Oklahoma Heart Hospital, one of those on Baker's roster, gets one star ("poor") for bypass surgery death rates in the hospital, at 30 days, and at six months. Baker doesn't concern himself with physicians' performance; he relies on the hospitals to find good surgeons and monitor them.

People who in the end decide to head abroad might consider a last bit of wisdom from those who have gone before: Think of it as medical "travel," and don't count on much "tourism." Few who arrive with a bad back or heart will be up to wandering through Bangkok or New Delhi. And after surgery and one or two weeks of recuperation, will you have the time, money, and energy to extend your stay? Oh, and on flights where coach will cramp your debilitated body and challenge your sanity, spring for business class.

Cross an Ocean, Save Big

Patients who need an elective procedure but lack health coverage and are ineligible for medical assistance will most likely bequoted list prices--the figures at left. (Medicare, as shown, usually pays hospitals a fraction as much.) Pckage prices in othercountries can be far below U.S. list prices. Getting a new hip in Thailand, say, could cost half as much as at a U.S. hospital, even after factoring in $5,000 in airfare for the patient and a companion and $150 per night for the companion's lodgings.

*Not reimbursable. Note: U.S. charges are list prices. Physician and certain other fees are generally excluded. Prices at non-U.S. hospitals are all-inclusive other than for Panama, which does not include surgeon's fee. Medicare amounts represent typical reimbursements to hospitals. Sources: Patients Beyond Borders, Centers for Medicare and Medicaid Services

By Avery Comarow