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Hip surgery in India? Insurance may pay

Timmi Ryerson, a San Diego stock market analyst, says her left hip actually works again, thanks to an orthopedic specialist in India.

Stacie Mason, a civil rights worker from West Virginia, couldn’t fully appreciate her 170-pound weight loss until a plastic surgeon in Panama removed 20 inches of excess skin from her stomach and back.

And Ford Davies, a firefighter from Roseville, Calif., sports a realigned jaw and a mouthful of straight, strong teeth courtesy of a dentist in Mexico.

What's new about these procedures is not the exotic locales the three chose, but the way they paid for their far-flung surgeries.

While at least 150,000 Americans travel abroad for medical care every year, according to the American Medical Association, Ryerson, Mason and Davies represent a small but growing category of medical tourist: patients whose insurance companies have agreed to foot at least part of the bill.

“I think that’s the solution to our health care crisis," said Davies, 53, whose company plan, Delta Dental, maxed out his dental benefit, about $2,500, toward the $30,000 he spent to repair damage caused by years of grinding his teeth, a procedure that would have cost an estimated $80,000 in the United States.

Increasingly, some of the nation’s larger employers and leading health insurers agree.

Once the province of the poor and uninsured, medical tourism is gaining attention of industry giants such as CIGNA, Aetna and Blue Cross/Blue Shield, who say they either have begun or are considering pilot programs that provide limited coverage for foreign care. One Montana firm, Employee Benefit Management Services Inc., recently began offering medial tourism plans to its 120 self-insured clients in the Northwest.

“That’s probably the big news in terms of all types of medical offshoring,” said Dr. Arnold Milstein, chief physician for Mercer Health & Benefits, an international health care consulting agency, and medical director for Pacific Business Group on Health, which represents 50 large regional employers.

“You’re beginning to see the point now that it’s changing from a market primarily of individuals without coverage or insurance to a circumstance in which this is going to be adopted by U.S. health insurance plans to extend to a much larger U.S. population.”

Lured by low-price luxury

It’s a trend applauded by insurers and patients lured by offshore prices that are a fraction of U.S. costs and care that advocates claim rivals luxury health spas.

But it also has sparked concerns among the nation’s doctors and wary insurance providers who worry about guaranteeing safety, quality and continued access to care when procedures are performed in foreign lands.

“It’s unclear at this time whether the risks outweigh the benefits,” said Dr. J. James Rohack, a board member of the American Medical Association, which recently issued first-ever guidelines for medical tourism.

Medical care outside the U.S. must remain an option, not a requirement, the doctors said. And incentives for offshore care should not be allowed to limit appropriate diagnosis, treatment or referral.

Patients should be referred only to institutions approved by the international arm of the Joint Commission, a key U.S. accreditation agency, or the International Society for Quality in Health Care, andthey should have wide access to information about doctors' credentials and outcomes, the guidelines said.

It's important to plan ahead for follow-up care back home, the doctors warned. And patients should be advised about the risks of combining surgery with long flights and vacation activities.  

"The concern is, you incentize patients to go someplace cheaper, they won't know all the risks," said Dr. Paul Sherman, a pediatrician and a medical director for Group Health Cooperative in Seattle.

Perks include air fare, lodging — for two

Insurers acknowledge they're considering a range of rewards aimed at motivating patients to choose foreign care.

"Basically, if you're going to present an option to an employee to get on a plane for five to eight hours, there will be a need to consider some sort of incentive," said Jackie Aube, vice president of product management for CIGNA.

Some plans may waive co-payments or reimburse patients for choosing less-expensive services. EBMS, the Montana firm, said that in addition to covering all medical costs, some plans will pay for air fare, lodging and other travel expenses for the patient — and a companion.

"The idea is if they choose to go offshore, the companion gets a little vacation," said Rick Larson, chief executive of EBMS.

Both proponents and critics acknowledge, however, that offering coverage could spark a medical tourism boom.

A May report by McKinsey & Co., a global consulting firm, estimated that if insurers began covering foreign medical care, between 500,000 and 700,000 Americans might head abroad for surgery each year.

Savings may top $20 billion a year

Savings for procedures performed on those patients could top $20 billion a year, the analysts said, providing a glimpse of the primary motive behind the burgeoning trend.

Countries such as India, Thailand, Singapore, Costa Rica and Korea offer medical procedures at a fraction of the cost of U.S. providers. A $130,000 heart-bypass surgery in U.S. may cost only $34,000 in Korea or as little as $6,650 in India, according to the newly formed Medical Tourism Association of West Palm Beach, Fla. A $20,000 hysterectomy in the U.S. might cost only $4,000 in Costa Rica — and it comes with a trip to Costa Rica.

No question, financial savings are at the heart of the interest, said Aube, of CIGNA, who noted that several large employers are considering offering coverage, but have not yet decided. But they're also motivated by the chance to provide more choice for consumers, she added.

That’s true, too, for Aetna, which has entered the market slowly, with a single employer, Hannaford Brothers, a Maine grocery store chain that has begun offering foreign coverage for hip and knee surgeries for its 27,000 employees. (So far, no one has taken them up on it, a spokesman said.)

And it’s behind the formation of Companion Global HealthCare Inc., a program of Blue Cross & Blue Shield of South Carolina, which provides overseas care as part of a package of health insurance plans. David Boucher, Companion’s assistant vice president of health care services, said he expects medical tourism to be a standard offering by 2015.

“I think the initial incentive will be for patients to avoid out-of-pocket costs and for employers to begin lowering their medical benefit costs a bit,” Boucher said. “But I am confident that what we will see is a steady stream of patients returning to the U.S. as true disciples of this opportunity.”

Top-notch care, a fraction of the cost

That’s certainly been the case for Mason, 43, whose $20,000 body lift in Panama last July included about $7,500 for surgery to remove a large flap of skin from her abdomen, a procedure called a panniculectomy. Because the excess flesh led to potentially dangerous skin infections, the surgery was deemed a medically necessary procedure, one that could be covered by her federal Blue Cross health insurance plan.

Mason paid the bill herself for the rest of the surgery, including breast augmentation and thigh lifts. Because her surgeries would have totaled $50,000 to $75,000 back home, she contracted with Planet Hospital, a California-based medical tourism service, to research the alternatives abroad.

Planet Hospital, which also arranged care for Ryerson and Davies, has been offering medical tourism services since 2002. Of the nearly 2,000 patients they've served since  2006, nearly three dozen have had some or all of their care covered by insurance, said Rudy Rupak, president and founder.

“It’s outrageous here, the cost of medical care,” Mason said. Additionally, many U.S. doctors seem to have forgotten that they’re providing a service, added Mason, who described one plastic surgeon she interviewed as “an egotistical ass.”

Not so with Dr. Louis Picard-Ami, a Florida-certified plastic surgeon who also practices in Panama. After checking out his credentials and the hospital’s safety record, Mason decided to go ahead with the surgery.

Not only was Picard-Ami technically proficient, he was kind and the amenities were luxurious, said Mason. Her hospital room was as lavish as any elegant hotel suite and her care included round-the-clock services of a private nurse.

“I just think that others need to be aware that they are able to have a safe procedure done out of the country for a price at a third the cost,” she said.

Ryerson, 61, said her private Blue Cross plan paid 80 percent of a $7,000 hip resurfacing surgery in Chennai, India, that would have been about $55,000 in the U.S. — if she could get it at all.

In 2006, the hip resurfacing device necessary for her surgery had just been approved for U.S. use by the federal Food and Drug Administration and not many domestic doctors had experience with it. Dr. Vijay Bose, her U.K.-certified surgeon in India, had performed the surgery more than 1,100 times.

“Doctors here didn’t know what they didn’t know and I didn’t want to be a guinea pig," she said.

While she was there, Ryerson also had cosmetic surgery and dental work done at her own expense.

‘I'm not going to Tijuana to get my teeth done’

Davies, the California firefighter, wasn’t sure he’d go ahead with extensive dental work until he met the dentist, Jorge Quintanilla, and toured the modern Mexican clinic where the procedures were performed.


Courtesy of Ford Davies

California firefighter Ford Davies, seen with his grandson, Regan, has a mouthful of new straight teeth courtesy of a dentist in Tijuana.

Image: Davies

1Pfalsefalse“At first I thought, I’m not going to Tijuana to get my teeth done,” said Davies, a former paramedic who quizzed the staff about where they got their water, how they cleaned their instruments and what sterile procedures they followed.

The dental staff was well-trained and compassionate, he said. And the assistants anticipated every need, from picking him up at the airport and filling painkiller prescriptions to driving him back over the U.S. border.

"They gave me what I wanted," he said.

Individual anecdotes are one thing, but critics of medical tourism said they worry about encouraging large numbers of Americans to seek care abroad. One of the reasons foreign care is so cheap is because of limited recourse for medical malpractice claims, for instance.

“It sounds great, two weeks’ safari and my hip for half the price,” said Sherman, of Group Health. “But what happens if something goes wrong? You are up a creek.”

The Joint Commission International certifies about 170 hospitals and medical centers worldwide. And many of the doctors who practice in hospitals frequented by medical tourists have been trained and certified in the United States.

Call for caution

Still, patients and insurers should remain cautious, especially in the early days of the burgeoning trend, noted Milstein.

“Without a doubt, just like for American surgeries, there will emerge as volume increases some horror stories, a terrible outcome preceded by a terrible hospital malfunction,” he said. “On the day that happens, the patient is going to point the finger at the insurance companies.”

That idea doesn’t deter the hip patient Timmi Ryerson, who said she won’t use U.S. hospitals for future surgeries.

“I really will not because of the cost and because of the quality of the medical care,” she said.

In fact, she’s planning now for a medical trip to Costa Rica in a few years. She figures she’ll need a mini face-lift and her new husband will require some work on his neck and his knees as well.

“They’ve got a place where you can go for medical care and it’s like going to a spa for month,” she said. “Who wouldn’t want that?”