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    America's New Refugees ― Seeking Affordable Surgery Offshore

    首席医学网      2007年01月05日 08:42:45 Friday  
     

    作者:Arnold Milstein, M.D., M.P.H., and Mark Smith, M.D., M.B.A.

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    【关键词】  New,Refugees,

    The mainstream media have begun to highlight the plight of some new refugees: seriously ill Americans who receive treatment at advanced private hospitals in low-income countries. These patients are not "medical tourists" seeking low-cost aesthetic enhancement. They are middle-income Americans evading impoverishment by expensive, medically necessary operations, as health care services are increasingly included in international economic trade.1

    At a recent Senate hearing, two stories were recounted that illustrated the physical and financial perils driving patients to pursue care abroad.2 In the first story, Howard Staab, a self-employed, uninsured, middle-aged carpenter from urban North Carolina who considered health insurance premiums unaffordable, had an acute mitral-valve prolapse, and his physician recommended surgery. The estimated total fees at the nearest regional hospital were $200,000, with a 50% deposit required in advance. A sympathetic hospital employee suggested that if the patient allowed his condition to deteriorate to a life-threatening emergency, the hospital would be compelled to provide the surgery and would afterward pursue debt collection. When he shopped elsewhere in the United States, he found a still-unaffordable best price of $40,000 at a hospital in Texas. Then, faced with the need to sell the family home, the patient's son, a medical student, found a cardiovascular surgeon, Naresh Trehan, who had trained at New York University and was practicing at a new, privately funded hospital in New Delhi, India. Trehan treated Staab, who paid combined hospital and physician fees of $6,700, and Staab returned to North Carolina and to work.

    Bonnie Blackley, a health benefits manager for Blue Ridge Paper Products, in Canton, North Carolina, told the second story. Rather than allow their mill to be put out of business by global competition, unionized workers had found private investors to help them buy the company. Although the company offered employees health insurance, Blackley had to pay close attention to health care spending. After implementing all conventional cost-management techniques, she decided to offer employees incentives of up to $10,000 per operation if they underwent required complex procedures, such as open-heart surgery and major joint replacements, at a credentialed hospital in India. She plans to begin with the nonunionized workforce and may later propose it in collective bargaining with unionized workers.

    (Figure)

      Blue Ridge Paper Products.

    Courtesy of the Asheville Citizen-Times.

    It is impossible to obtain trustworthy information on the magnitude of this trend in care seeking, because payments to foreign hospitals and physicians are not tracked as a distinct category in balance-of-trade statistics. But advanced hospitals in low-income countries such as India and Thailand report steady annual growth in the numbers of American patients they see. At Bangkok's Bumrungrad International Hospital, for example, 55,000 Americans were treated this past year, 30% more than in the previous year3; about 83% of them underwent noncosmetic treatments.

    The enormous price advantage obtained by the Staab family and others seeking offshore surgery primarily reflects the lower wages paid to physicians and other health care workers in those countries. It also reflects cheaper prices offered in low-income countries by global suppliers of medical devices and other health care products.

    To ensure both significant savings net of travel expenses and patients' safety, such offshore care must be limited to nonurgent, short-duration treatments costing more than $15,000 to $20,000 in the United States for conditions that aren't exacerbated by air travel; these include major cardiac and orthopedic procedures. We estimate that treatments meeting these criteria currently account for less than 2% of U.S. spending on noncosmetic health care for worker households (excluding care for U.S. residents who live along the Mexican border).

    The trend is driven by the escalation of out-of-pocket spending for health care and insurance premiums beyond the grasp of low- and middle-income Americans ― an escalation that is forcing many workers to forgo health care and insurance coverage. There is a direct relationship between the cost of insurance premiums as a percentage of income and the proportion of employees who decline coverage; in some low-wage industries, more than 75% of workers who are eligible for benefits turn down employer-provided health insurance. This response is understandable: in 2006, the average health care expenditures for a family of four for the first time exceeded the entire annual earnings of a minimum-wage worker.4 As health care spending continues to increase more rapidly than the gross domestic product, coverage is becoming unaffordable for more and more working people; the proportion of worker households doing without health insurance is growing most rapidly among middle-income workers, who are not eligible to receive state- or employer-sponsored low-income subsidies.

    Unlike Americans who earn lower wages, many carpenters like Staab and paper-mill workers like those at Blue Ridge have substantial home equity and other financial assets that they want to protect from the collectors of health care debts, whose position has been strengthened by newly tightened criteria for declaring personal bankruptcy.

    One important question about advanced foreign hospitals is whether their quality of care is similar to that in the average U.S. hospital. In recent years, many such hospitals have passed muster with one or both of two international quality-assessment organizations. Certification bodies accredited by the International Organization for Standardization, known as the ISO, have certified hospital quality-management programs in, for example, Mexico, India, Thailand, Lebanon, and Pakistan. The Joint Commission on Accreditation of Healthcare Organizations, which accredits most U.S. hospitals for participation in the Medicare program, has accredited more than 80 non-U.S. hospitals in India, Thailand, Singapore, China, and Saudi Arabia, among other countries, through its Joint Commission International (JCI) affiliate. Many of the ISO-certified and JCI-accredited hospitals employ physicians like Tehran who trained and often obtained board certification in the United States or another high-income country.

    Since the United States and most other countries do not require their hospitals to measure and report surgical outcomes or to participate in international performance-measurement systems, it's hard to assess relative quality. We doubt, however, that the average U.S. hospital can offer better outcomes for common complex operations such as coronary-artery bypass grafting, for which several JCI-accredited offshore hospitals report gross mortality rates of less than 1%. Moreover, with respect to the patient's subjective experience, Howard Staab's wife describes her family's recent care at U.S. hospitals as far worse than that her husband received in New Delhi. However, had her husband suffered from medical negligence abroad, the avenues for redress would have proved more limited than those available in the United States.

    Will the growing number of visits by U.S. citizens seeking surgery abroad adversely affect residents of developing countries? A recent analysis by a World Bank economist suggested that this risk was minimal and that the influx of revenue associated with this practice might bolster the health care industry in developing countries, providing an opportunity for them to repatriate health care professionals ― who currently account for a substantial fraction of the physician and registered-nurse workforces in the United States.5

    American physicians who are concerned about the growth of this phenomenon have two choices: they can denounce and attempt to restrict it, or they can lead and more actively support efforts by others to speed the discovery and uptake of more efficient domestic health care delivery methods. The opportunity is substantial. In a 2005 Institute of Medicine (IOM) report on the application of systems-engineering approaches to care delivery, one author estimated that 30 to 40% of current U.S. health care expenditures are wasted, primarily on the provision of services unlikely to boost patients' health status or their satisfaction and on the inefficient provision of valuable services.

    Offshore surgery, which currently represents an opportunity to lower prices for at most 1 to 2% of total U.S. health care spending for worker households, is a symptom of, not a solution to, our affordability problem. The symbolism of such "offshoring" of lifesaving operations, however, should not be lost on U.S. physicianleaders. In response to the IOM's new report on pay-for-performance initiatives, they will once again consider the institute's call for the redesign of clinical work to better achieve the essential aims of health care. With regard to the aim of efficiency, low- and middle-income Americans need physicians to respond quickly and affirmatively, and they need the resulting reconstructive procedure to be fundamental, rather than cosmetic.

    Source Information

    Dr. Milstein is the chief physician at Mercer Health and Benefits and medical director of the Pacific Business Group on Health ― both in San Francisco. Dr. Smith is the president and chief executive officer of the California HealthCare Foundation, Oakland, CA.

    References

    Wachter RM. The "dis-location" of U.S. medicine -- the implications of medical outsourcing. N Engl J Med 2006;354:661-665.

    The globalization of health care: can medical tourism reduce health care costs? Senate Special Committee on Ageing witness testimonies, June 27, 2006. (Accessed September 25, 2006, at http://aging.senate.gov/public/index.cfm?Fuseaction=Hearings.Detail&HearingID=182.)

    Kher U. Outsourcing your heart. Time. May 29, 2006:44-7.

    California HealthCare Foundation. Health insurance: can Californians afford it? 2005. (Accessed September 25, 2006, at http://www.chcf.org/documents/insurance/HealthInsuranceAffordability.pdf.)

    Mattoo A, Rathindran R. How health insurance inhibits trade in health care. Health Aff (Millwood) 2006;25:358-368.

     

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