Exporting patients: Money versus possible safety issues

Blue Ridge Paper Products Inc. of Canton, N.C., claims to be the first paper mill to make bleached pulp out of southern pine trees, the first to print paper out of that pulp, and the first to use the bleached filtrate recycling process for minimizing pollution. Now, in its 101st year of operation, Blue Ridge is establishing another, radical first that raises questions about the future of patient care -- it sent an employee overseas for an insurer-covered surgery.

This month, a Blue Ridge worker headed to New Delhi to have his gallstones removed and his rotator cuff repaired. Blue Ridge has added overseas hospitals and physicians to its PPO.

For Blue Ridge, it costs less to send an employee 7,800 miles to New Delhi than nine miles to the nearest hospital -- with the quality being equal in the company's eyes. The company estimates the employee's surgeries would cost $100,000 in North Carolina but $20,000 in India.

"We want better than what we can get here," said Darrell Douglas, vice president for human resources. Blue Ridge is even kicking in for travel expenses and paying employees a bonus of up to $10,000 for going to India.

It used to be that "medical tourists" were looking for less-expensive alternatives for cash-only procedures, such as plastic surgery, or seeking medicine or procedures not approved here.

But the combination of rising medical costs and a greater emphasis on consumer-directed care has self-insured companies and insurers expanding the map of where employees and members can get treatment. Overseas hospitals have taken notice, pitching their services to American companies and lining up in increasing numbers to be accredited by the Joint Commission on Accreditation of Health Care Organizations. Some 100 hospitals all over the world are accredited, including the one Blue Ridge is using in New Delhi.

The U.S. Senate's Special Committee on Aging in June held hearings on medical tourism, with supporters noting it's a way to strike back at the spiraling expenses of the U.S. system. But Bruce Cunningham, MD, president of the American Society of Plastic Surgeons, noted there are concerns, particularly in regard to patient safety. For example, what about follow-up care? If things go wrong, is the patient supposed to go back to India?

"For those who choose to go overseas for elective surgical procedures, there are a number of critically important issues to consider," Dr. Cunningham told the committee. "Without a complete understanding of the medical standards for the health institution or facility, medical providers, surgical training, credentials and postoperative care associated with surgery, a patient can be ill-informed and worse, at significant risk."

But in an interview with AMNews, Dr. Cunningham said the apparent willingness of more patients to consider going overseas -- and the presence of patients at the hearing who said they believed the quality of care they received was superior to what they could get here -- is revealing.

"This is very sobering if it's true," Dr. Cunningham said. "We need to wake up and realize we're being challenged."

Big savings

The lure of huge savings is tempting for payers: Blue Ridge testified at the Senate hearing, and one West Virginia state legislator has introduced a bill that would allow state employees to fly first class, with their families, stay at a four-star hotel and receive extra sick days in order to get cheaper care overseas.

United Group Programs, a third-party administrator based in Boca Raton, Fla., outlined why it anticipates a receptive audience for its overseas network. The average cost of a kidney transplant in the United States is around $73,000, versus $28,000 at Bumrungrad International Hospital in Bangkok, Thailand. Time magazine reported that Bumrungrad last year treated 55,000 American patients -- a 30% increase over 2004.

A coronary artery bypass costs roughly $6,500 at Apollo Hospitals in India, while surveys show the average cost in California is $60,400 -- a difference that is more than enough to make up the travel costs.

"We got into it because health care costs in the United States have gotten out of hand," said Jonathan Edelheit, vice president of sales for United Group. "It can reduce costs by 80%. It's the only thing considered to be a magic bullet."

It's the magic bullet Blue Ridge is aiming at health costs that have doubled over the last five years, to $9,500 per employee.

Meanwhile, hospitals and so-called medical tour operators are also working to sell Americans on the idea that they don't have to scrimp on medical quality to get a lower price.

Since the early 1990s, Joint Commission International, the international branch of JCAHO, has accredited more than 100 hospitals outside the United States. Already India, one of the most popular destinations for Americans, has five JCI-accredited hospitals, with more signing up.

JCI Executive Director Anne Rooney said the accreditation process mirrors the U.S. one, with modifications to fit the country's individual situation. It can take up to three years and costs up to $30,000, but Rooney said business is booming.

In order to receive JCI accreditation, the foreign hospital must meet the specific country's safety standards, Rooney said. The hospital must also have a process to appropriately refer patients to a U.S. facility that can meet their continuing care needs. Other criteria govern lab results, patient and family rights and nutrition. The guidelines also require the hospital to keep up-to-date licenses, certificates and credentials for all medical staff members, with credentials to be evaluated at least every three years.

"Over the last seven years, the awareness has really grown," Rooney said, who added that new JCI offices will soon open in the United Arab Emirates city of Dubai and in Singapore.

Alain Enthoven, PhD, senior fellow at the Center for Health Policy in Stanford, Calif., and a long-time advocate for consumer-directed health care, said physicians and hospitals should pay close attention to the medical tourism industry because it's likely to change the mind-set of Americans who once thought of other countries' health systems as inferior to that of the United States.

"There are medical centers in Asia and perhaps elsewhere that are working very hard to develop first-class medical care for costly procedures. ... They are out to achieve a reputation for excellence," Dr. Enthoven said.

Questions on outsourcing

Kenneth Ouriel, MD, is chief of surgery at the Cleveland Clinic, a popular destination for people from other countries who want the quality of the U.S. health system. But Dr. Ouriel, a vascular surgeon, said he's not sure he's comfortable with patients going the other way, especially if it's solely motivated by cost.

Dr. Ouriel said traveling overseas for surgery can be risky, especially if something goes wrong. One of his patients ended up spending weeks, instead of the planned days, in a German hospital following complications during back surgery.

In addition, Dr. Ouriel said he is concerned about the coordination of care between U.S. and foreign physicians.

Dr. Cunningham also noted that many foreign countries have relatively weak patient protection laws, compared with those that Americans are accustomed to, making it difficult should a malpractice situation occur, he said.

Some also worry that the flow of insured patients into overseas hospitals represents a form of cherry-picking of the wealthier patients whose money helps support charity care.

"If these are the people who are insured and they do not go to the hospital in the United States, that presents a problem," said Joel Miller, vice president of operations at National Coalition on Health Care. The coalition is a nonpartisan group of 100 employers, unions and associations, including the American Academy of Family Physicians and the American Academy of Pediatrics.

"It may take some time to rear its ugly head, but it certainly has implications if this becomes widespread," Miller said.

Arnold Milstein, MD, chief physician at Mercer Health and Benefits, a human resources consulting firm, and medical director of the multiemployer Pacific Business Group on Health, said physicians don't need to worry yet about their patients jumping en masse on a plane to India for care.

"It's unlikely to have a major impact on the American health care system because the range of patients for which this is a good solution is a relatively small percent of health care spending," he said. Dr. Milstein, speaking before the Senate's Special Committee on Aging, said he expects most patients who have the option to go overseas will instead stay in the United States for the "emotional benefit" of having family close by and for the greater redress they could seek if something went wrong.

Dr. Milstein, in his prepared remarks to the committee, called medical tourism not a solution but a "symptom" of an inefficient, ever-more expensive U.S. health system that is squeezing the middle class as it further becomes out of reach for the poor.

"Until America's major public and private payers better collaborate in creating a profoundly more performance-sensitive environment around American physicians and hospitals, well-engineered care delivery, will remain conceptual and our hospitals will continue to fall short in international value benchmarking. And more uninsured, underinsured and insured non-wealthy Americans will board international flights to obtain lower-cost surgery at levels of quality that cannot be distinguished from American hospitals."