A ‘Case Study’ in Implementing Medical Tourism into Workers’ Compensation

Note: This case study is fictional. It was created to show what is possible for medical tourism to bring down the high cost of certain surgical procedures performed in US hospitals, and to show that employers, especially those already using medical tourism as an option on their self-funded employee health care plans can do so with workers’ compensation claims. The costs mentioned below are from the following website:

http://www.medicaltourism.com/en/compare-costs.html

Three construction workers, Juan, Pablo and Jorge, were working on a construction site, neither man operating heavy equipment. Juan was working with Jorge, putting up drywall, and standing on scaffolding, about ten feet off the ground. Pablo working at the other end of the scaffolding from Juan and Jorge painted the drywall they both put up earlier. As Juan wen to reach for another sheet of drywall, he lost his footing, causing the scaffolding to buckle. But when Jorge tried to catch him, the scaffolding gave way, and all three men fell to the ground.

Juan, who was from Mexico, fell on his left side, injuring his left hip. Jorge, from Costa Rica, had managed to face forward when he fell and hit the ground, injuring his left knee. Pablo, from Colombia, also fell forward, as he put down his paint brush and paint can when the scaffolding began to buckle, and hung it on a hook on the outside left post of the scaffolding. Pablo managed to fall on his right knee, injuring it as well. All three were sent to an orthopedic doctor’s office their employer selected from a list prepared by their state’s workers’ compensation bureau.

They were treated by the doctor, and given prescriptions for pain medication, and were told they could return to work if they felt no discomfort. A week later, all three complained of pain and said they could not work. They filed workers’ compensation claims with their employer. When they went back to the treating doctor, he told them that since they initially did not complain of any serious pain or discomfort, he treated them for the contusions and other superficial injuries, but now order that all three get MRI’s for their injuries.

The MRI on Juan found a hip fracture that owing to his age, suggested a total hip replacement, otherwise he would never be able to walk normally, or even work. Jorge’s MRI showed a fracture of the left kneecap, and Pablo’s showed a similar fracture, but on the right knee. It was further determined that both Pablo and Jorge had injured their ACL’s as younger men playing soccer in their home countries, so it was recommended by the orthopedist that they both get knee replacements as soon as possible.

When their employer was informed of this by their insurance carrier, their Risk Manager happened to speak to the company’s Employer Benefits Manager, who recommended he look into getting the men treated in their home countries through medical tourism. The Risk Manager had never heard of medical tourism, so he asked the Benefits Manager to explain how it works. The Manager told him that the company is self-insured for their employee’s health care plan, and as an option, they allow their employees to choose to get treatment abroad through a medical tourism facilitator company they have contracted with.

When the Risk Manager heard about the self-funded plan option, he wondered if this could be something he could use for his three workers’ compensation claims. He told the Benefits Manager that the hip and knee replacements would cost $50,000 each, and even though the insurance carrier was going to pay for it, it was going to affect his claim severity, which would impact his experience mod, causing a rise in insurance premiums. The Benefits Manager told him that if they so choose, they can each get their surgeries in their home countries at lower cost, and at the same or better quality than in US hospitals. The Risk Manager asked the Benefits Manager to get him comparative prices for each procedure in the three home countries of the injured workers, and he would try to get the insurance carrier to go along with it.

A couple of days later, the Benefit Manager sent the Risk Manager the following table comparing hip and knee replacement costs in the US with the costs for each in Colombia, Costa Rica and Mexico. As seen in Table 1, a hip replacement in Colombia cost $6,500. In Costa Rica a hip replacement cost $12,500, and in Mexico a hip replacement cost $13,000. Knee replacements in each country were as follows: $6,500 in Colombia, $11,500 in Costa Rica, and $12,000 in Mexico.

Table 1


The insurance carrier was unsure of the quality of treatment and skill of the treating physicians in those countries, but as the company vouched for their quality and skill from the employees who had used it under the self-insured health care plan option, they agreed as long as the company was satisfied this was what the employees wanted. All three men, when told of the option of being treated in the US or in their home countries, opted to take the medical tourism option. What had made it possible for them to choose this as an option was the fact that the total cost of the procedure included airfare for each man and his spouse, plus accommodation, as well as the cost of the surgery and hospital stay.

As Juan had older children, his oldest married and living close by to the family; they could watch the other children while he and his wife were away. Jorge’s children would stay with his wife’s relatives nearby, and Pablo’s children would come with him and his wife, since he was able to find a low fare for the two young children. Also, the fact that the hospitals they were going to were some of the best in their home country, made them feel better of themselves that they could get such great care at a very good hospital. It would help their self-esteem and make their friends and families back home very proud.

When they returned to the US, they had healed much faster and in better spirits had they not chosen this option. Although they could not work again at their old jobs, they nevertheless got good jobs with the same company that did not put them in such dangerous positions before their accidents. They became more productive as a result and their employer was pleased with the outcome. The Risk Manager with the approval of the president of the company, included a medical tourism option for all future severe workers’ compensation cases.

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This entry was posted in Health Care, Medical Tourism, Workers' Compensation and tagged , , on by .

About Transforming Workers' Comp

Have worked in the Insurance and Risk Management industry for more than thirty years in New York, Florida and Texas in the Claims and Risk Management spheres, primarily in Workers’ Compensation Claims, Auto No-Fault and Property & Casualty Claims Administration and Claims Management. Have experience in Risk and Insurance Business Analysis, Risk Management Information Systems, and Insurance Data Processing and Data Management. Received my Master’s in Health Administration (MHA) degree from Florida Atlantic University in Boca Raton, Florida in December 2011. Received my Master of Arts (MA) degree in American History from New York University, and received my Bachelor of Arts (BA) degree in Liberal Arts (Political Science/History/Social Sciences) from SUNY Brockport. I have studied World History, Global Politics, and have a strong interest in the future of human civilization in all aspects; economic, political and social. I am looking for new opportunities that will utilize my previous experience and MHA degree. I am available for speaking engagements and am willing to travel. LinkedIn Profile: http://www.linkedin.com/in/richardkrasner Resume: https://www.box.com/s/z8rxcks6ix41m3ocvvep

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