Monthly Archives: May 2013

The Faith of My Conviction: Integrating Medical Tourism into Workers’ Compensation is Possible and is not a Pipe Dream


 Merrell: “…Can you see a role of medical tourism in workers’ compensation injury?”

Ludwick: “I could, if it were a long-term issue. Many workers’ comp issues are emergent,
so that would take out the medical tourism aspect. However, if it was a long-range issue,
I could see us involving workmen’s comp issues into that, or problems.”
Lazzaro: “I would support that. I don’t know the incidence, for example, of some of the orthopedic procedures that are non-emergent, such as knee or hip replacement, which would fall under workmen’s comp. But theoretically, a case could be made for that…”
Merrell: “I was thinking about it in terms of the chronic back injury and the repetitive action injuries and hernia that are in the workers’ compensation area. An acute injury on the job would probably not be at issue but a work-associated problem with a potentially surgical solution might be a matter for medical tourism.”

When I was researching for my term paper for my Health Law class, which later became my white paper, Legal Barriers to Implementing International Medical Providers into Medical Provider Networks for Workers’ Compensation,I came across the above discussion, and had a proverbial light bulb moment. It was the first time that I actually believed that what I was attempting to write about, was actually possible because of the expert commentary cited. But in the six months since I began this blog, I have been finding that what I so strongly believed at the time was possible, and still do believe is possible, is not possible according to some other experts in the field of medical tourism.

Yet, in going over in my mind what Dr. Merrell, Ms. Ludwick and Mr. Lazzaro said back in 2008, and weighing the skeptical comments I have been getting of late about my ideas, it occurred to me that these three distinguished individuals cannot possibly be wrong, if others say it cannot be done. Dr. Merrell was at the time, the Editor-in-Chief of Telemedicine and e-Health, and the Chairman of the Department of Surgery at Virginia Commonwealth University’s School of Medicine. Ms. Ludwick is the President of the Health Care Compliance Association, the leading trade association for third-party administrators, and someone intimately knowledgeable about the workers’ compensation claims process from the point of view of third-party administrators. Mr. Lazzaro is the Managing Director of Tivis Capital and CEO of Bridge Health international, and is an expert on surgical and other medical services in China.

And in the confusion and frustration that accompanied my doubt and anguish over this realization, I determined to press ahead anyway and write this post in the firm conviction of my faith that such an integration of medical tourism into workers’ compensation is not only possible, it is imperative, not only for the sake of the injured worker’s treatment, the employer or the insurance company’s savings, but for the entire medical community on Earth. Integration is the only way forward for the human race if we are to survive. But it won’t be easy. It will take courage, vision, hard work, and a lot of idealistic dreaming, but it will become a reality. Medical care will be global, just as everything else will be, and the time to begin the process is now, not a hundred or two hundred years from now.

How that integration will be possible is the subject of this article, and one way this can be achieved was presented this week in an article on Insurance Thought

The Integrated Care Management Model

An integrated care management model for workers’ compensation will be a game-changing phenomenon that will improve results throughout the entire systems, says Don Duford, Chairman of the Board of One Call Care Management recently in an article for Insurance Thought The article, Game-Changing Strategies To Transform Workers’ Compensation, describes how the workers’ compensation system faces three major challenges, and offers a solution to these challenges.

Duford identifies the three challenges as follows:

  • Reducing the spiral of rising costs for claims
  • Improving outcomes for medical care, and
  • Streamlining efficiencies which impact both care and cost

As I mentioned in my recent post, Average Medical Claim Costs Still Rising for Workers’ Compensation, and in my white paper, Duford cites statistics from the National Council on Compensation Insurance (NCCI) that states that workers’ compensation medical costs continue to rise, and now constitute 60% of total claims costs, as opposed to the 58% I originally mentioned in my white paper two years ago. In addition, the average medical cost of lost-time claims has more than tripled since 1991, as indicated in the table below, and nearly doubled since 2001, ten years later.


The Workers’ Compensation Research Institute (WCRI) reported that outpatient hospital average payments per claim rose 31% from 2006 to 2010, and inpatient hospital payments per episode rose 36% in the same period.

Some of the drivers of these costs, Duford points out are:

  • The growing opioid epidemic, which I have written about in past posts on this blog and elsewhere.
  • Co-morbidities and obesity
  • An aging workforce
  • Variations in care by provider and by state
  • The fragmentation of care management, and
  • The impact of providers can vary widely, especially if they are not experienced in workers’ compensation cases that use an assertive “sports medicine” approach that deploys and manages treatment from the beginning to achieve rapid recovery and return to work.

Duford’s solution calls for finding and using superior practitioners, which is the key to getting the best care for injured workers, and reducing overall costs. Such outcomes-based networks with superior providers, Duford says, can reduce total claim costs by 20 to 40 percent. Also, rapid interventions with the right therapies, means that the worker is more likely to recover faster and have a better outcome.

He cites three capabilities currently in today’s marketplace that will enable this change:

  • The ability to develop strong networks of specialty “best-in-class” providers who contribute to all elements of care in workers’ compensation, and who receive scrupulous credentialing and consistent quality oversight to ensure an aggressive focus on evidenced-based medicine and fast return-to-work.
  • Advanced analytics of claims data that can determine the providers who generate the best outcomes.
  • Technology that is easy-to-use, and that connects a broad range of providers with claims professionals, leading to the expediting of fast referrals and treatments, overall care coordination and prompt reporting or test and care results.

How medical tourism can be integrated into workers’ compensation

Naturally, Duford does not include medical tourism into this model, but by using this model as a guide, we can, and should include medical tourism into this model by recognizing that like most other processes, a workers’ compensation claim has a beginning, middle and end point, and the providers in Duford’s model represent links in the supply chain we call a workers’ compensation claim.

If the goal of the process is to get an injured worker back to work faster, with a greater outcome of care then as the worker moves from one point of the supply chain to another, a decision tree is formed that answers the question: “Is the worker able to return to work, yes or no?” If yes, then there is nothing more that can be done, and the process stops. But if the question is answered with a no, then the next step in the chain takes over, until you come to the point at which surgery is required, then the question is not “is the worker able to return to work”, but where can the worker get the best medical care, at the lowest cost and highest quality that will save the employer and or the insurance carrier money.

Duford’s model does not include medical tourism destinations, but if it did, that last question would certainly be part of the model, because to leave out the possibility of lower cost medical care at the same or better quality than what is available in the US, is shortchanging the worker, the employer, and the insurer.

Medical tourism then can be integrated as part of the end point of the supply chain, but will be dependent upon all the other activities that preceded it, much in the same way that the store that sells a certain product is dependent upon the manufacturers who made the parts that went into making the final product which they sell.

Which brings me back the quotation at the beginning of this article. Merrell, Ludwick and Lazzaro all agree that there is a place for medical tourism in workers’ compensation, and they all agree that non-emergent care, i.e., those injuries that do not require a worker to be rushed to an emergency room or operating room immediately after an injury, are good candidates for medical tourism. And if they are correct, then adding medical tourism to Duford’s model will not only improve the outcomes for patients, but will improve the bottom line of their employers and the insurance companies that pay for medical tourism.

Afterword and Conclusion

I mentioned earlier that I have been receiving skeptical comments about my ideas on medical tourism and workers’ compensation that fly in the face of what Merrell, Ludwick and Lazzaro said previously. As part of these and other comments, the issue of standards and regulations and laws came up that I was told will prevent this integration from ever taking place. I was told that it would take a hundred years or so to get international standards, that it was a pipe dream, or that because of politics, custom, culture, etc., these laws are difficult to change. But change they must, because to not change will only lead to stagnation and even worse.

I have even been told that I should cite market research to bolster my argument, which of course is true in certain circumstances, but not here when I am staking my firm faith and conviction on the future course of global medical care for all people, not just those who have money to travel or who have great insurance. Yet, relying here and now on market research reminds me of the three kinds of lies: lies, damned lies, and statistics, so the reader will have to excuse me for not citing the latest market research that says such integration cannot be done or will not be done.

I then realized that behind the comments was something bigger, something that had until then escaped me. It was not who these people were, because I respect them and their accomplishments and their expertise, but what I realized was that there is a form of protectionism going on between countries, hospitals and other facilities and providers that like all other forms of protectionism, not only hinder progress, but also run counter to basic economic truths that goods and services will migrate to those areas where goods and services will be cheaper to produce. Such is the case, no matter what we personally think of it, with the globalization of jobs and services outside of health care today, so why should health care be any different?

It shouldn’t, and like all visionaries, I take it as a matter of faith, that this will happen in health care too. It may take a hundred years to do so, but when will we take the first steps towards that goal, now, or in a hundred years from now? The Chinese say a journey of a thousand miles begins with the first step. Do we in health care wait until we take our thousandth step, or do we begin right here, right now? The answer is right in front of us, all we need is vision, courage, faith, and hard work, things that are desperately lacking in so many people.

I call it as I see it, with no apologies to anyone necessary…Think about what I’ve said.

If You Have to Ask…Fuggedaboutit!

th (1)

Trans·par·en·cy: the quality or state of being transparent. Origin:  Medieval Latin trānspārentia. Source:

Transparency, a simple enough word, one that conveys the idea that something is transparent, clear, understood, can be easily recognized and seen; yet, a word that the medical tourism industry, and the health care industry at large has so far failed to grasp. This lack of transparency is clear, or rather transparent to anyone who has tried to figure out the cost differentials for treatment procedures from one part of the US to another, let alone from one country to another, for the same procedures.

This is the dilemma I have been encountering for some time as I have been writing this blog. I have tried to approach several of my contacts in the medical tourism industry to get information on certain surgical procedures such as hip, knee, spinal fusion, carpal tunnel, and other occupational-related surgeries so that those in the workers’ compensation industry in the US can compare apples to apples, oranges to oranges, as best as possible, given the number of hospitals in the Caribbean and Latin America region that cater to medical tourism. Unfortunately, I have run into difficulty getting this information for a variety of reasons.

One reason is that some of my contacts are busy with their own affairs to get such data from the hospitals, and then forward it on to me. I quite understand that, and can appreciate that if it was me, I, too would be too busy to do so. But in the case of one of my contacts, who has been more than generous with her time and assistance, we have been frustrated by bureaucracy, politics, and turf battles between hospitals in the same group, and in the same country.

It should be a simple thing to quote a price for a particular surgical procedure such as a hip replacement or a knee replacement. Even if it is an average of a range of prices, it is still better than guessing or taking it on faith that medical tourism destinations are less expensive than US hospitals, with or without the cost of airfare, accommodation and other expenses factored in. For example, in one of my earlier posts, I included the following table to compare hip and knee surgeries costs in Colombia, Costa Rica and Mexico with that of US costs.


How accurate are these figures is anyone’s guess, but at least when you look at the four countries listed, there is a discernible difference in cost, not only between that charge in the US, but between the three Latin American countries as well.

To further illustrate what I mean, and to show that transparency of prices is not limited to the Latin American region, the next table, which I cited in my white paper on medical tourism and workers’ compensation, shows price differentials between the US, India, Singapore and Thailand, and includes airfare and accommodation for two.


As the Center for Medicare and Medicaid Services (CMS) recently did here in the US with hospital charges for spinal fusions, so too should the medical tourism do the same for all procedures, at all hospitals and in all countries. Spinal fusions at the top 10 American hospitals range from $269,846 to $471,121, and overall, between $19,000 and $470,000.

It should not be so hard to find out the same kind of information from a hospital in a country that is establishing itself as a major medical tourism destination. While the American workers’ compensation industry only accounts for 2% of the health care market in the US, that market in and of itself is pretty large, and should not be ignored, especially as the American workforce is getting more and more Hispanic, and in particular, in states like Arizona, California, Colorado, Florida, Nevada, New Mexico, and Texas, as well as other states in the union with a growing Latino presence.

So, transparency, a simple word that can be defined simply as the state or quality of being transparent, clear and understood, needs to be the most important idea when any country or hospital in that country wants to pursue medical tourism business, no matter if it is from private individuals, group health care plans, or workers’ compensation insurers and employers covered under that insurance or by self-insured coverage. Transparency needs to be transparent.

Average Medical Claim Costs Still Rising for Workers’ Compensation

The National Council on Compensation Insurance (NCCI), the national reporting bureau for workers’ compensation data reported its 2013 State of the Line Report yesterday. Those of you who have read my White Paper on the implementation of medical tourism into workers’ compensation will recognize the chart below as similar to the one in my White Paper.

The State of the Line report is given every year at the Annual Issues Symposium held in Orlando, Florida. This is the last year that the Chief Actuary, Dennis Mealy is giving the report, as he is retiring, according to Joe Paduda in his blog.

The chart shows the years from 1991 to 2012, with the average medical costs per lost-time claims (any claim beyond the statutory waiting period and for which the claimant is receiving benefits). In addition, the chart shows the average percentage change between the previous years’ medical costs and the current years’ medical costs.


As I mentioned in my paper, the trend still appears that medical costs are going up, even if the percentage change has gone down. The next chart highlights this trend for the average medical cost per lost-time claim.


To illustrate what this means, consider this exchange between Mr. Jones, who has a terminal illness, and his doctor:

Doctor:       “Good news, Mr. Jones. We’ve managed to slow the progression of your disease.”

Mr. Jones:   “What’s so good about that? I’m still dying, only slower.”

In each year’s report, the last year is a preliminary figure which is revised once all data is reported to NCCI. This is also true for other years, as the nature of workers’ compensation data reporting is to require insurance companies to report ten years’ worth of data to NCCI.

As reported by Joe, average medical claim cost was up 3 percent from last year, as you will see in the chart. Yet despite the cautious optimism, the trend is for the average medical claim cost to get closer and closer to $30,000, and may yet surpass that amount in the next several years.

While there is no way to tell if these figures include the cost of surgical procedures for lost-time claims, it is reasonable to assume that the total cost will be much higher. This is where medical tourism will benefit the workers’ compensation industry, because it can offer lower cost medical care at the same or better quality than that available in the US.

Why the workers’ compensation industry continues to delude itself and its insured’s that costs are coming down is beyond me? But one thing is certain, they are not availing themselves of an option that offers tremendous cost savings and will provide the patient with faster recovery and quicker return to work — medical tourism.

The IMTCC Is What Medical Tourism Is Supposed To Be

logo 200x200

I’d like to take this opportunity to introduce you to another one of my LinkedIn connections, who is part of the medical tourism industry. Her name is Christina de Moraes, and she is the CEO and founder of the International Medical Tourism Chamber of Commerce (IMTCC), located in California. Christina has been involved with medical tourism, as both a patient and a patient advocate for more than ten years when she first began her “Medical Concierge” services in Brazil.

She was the President and founder of MedNetBrazil and MedNetCostaRica from 2002 to 2012, and she has been a consultant for the Medical Tourism Industry, as well as a Patient Advocate and Plastic Surgery Consultant for the very specific techniques of Post Massive Weight Loss Reconstruction and Brazilian Plastic Surgery techniques, as well as bariatric surgeries.

Christina has spent 10 years as a cultural, medical, social and business liaison between her patients, her company and Brazilian medical providers, marrying the needs of each to achieve mutual benefit, create trust, improve results and implant ethics in medical tourism facilitating.

She founded the IMTCC in May 2012. Her reason in founding the IMTCC was so that medical tourism consumers/patients, health care providers, and medical tourism service providers could have an unbiased source to guide them on matters of competence and trust.

There are three tenets of medical tourism that members and providers are committed to providing so that patients will have a safe and successful medical tourism experience. The three tenets are:


The IMTCC’s Mission Statement expounds on the three tenets and lays out the mission of the IMTCC as a reliable and trustworthy organization committed to the highest standards.

IMTCC Mission Statement

To Formally Declare, Endorse and Implement the Three Tenets of Medical Tourism:

ADVOCACY, AFTERCARE and ACCOUNTABILITY … Paving the Way to Accreditation Standards

Provide a Leadership Role in Advancing Marketplace TRUST and Industry INTEGRITY

Set Best Standards of Practice and Patient Centered Care Delivery, Regardless of International Borders.

Epitomize Result and Performance-Based Membership Standards and Transparent Reporting Practices

Promote the Use of Best Standards of Practice by Offering Coordinated Workflow Protocols and Homogeneous Patient Care Processes

MACSS – Medical Aftercare and Concierge Support Services

Provide Training, Mentoring and Constructive Feedback to Chamber Members as a way to add integrity and value to the Services and Expertise They Offer to Patients.

Create an International Network of Accomplished Medical Tourism Services Providers and Preeminent Healthcare Professionals

Provide Education and Unbiased Advice to Patient Consumers and the Marketplace

Represent the VOC – Voice of the Customer – to Healthcare, Insurance and Medical Tourism Providers

Denounce Substandard Industry Performance, Behaviors and Practices Through Unbiased and Diligent Compilation and Transparent Disclosure of Important Industry Outcomes, Complication Rates and Patient Satisfaction

Celebrate Both Healthcare and Industry Role Models, Visionaries, Motivators and Innovators

Become Internationally Recognized as the Trustworthy Resource to Turn to for Objective, Unbiased Information on Medical Tourism and International Healthcare Providers.

Promote the Three Tenets as a Global Model and Catalyst for Change in the Delivery of Healthcare

As the medical tourism industry is still a relatively new and growing industry, there are problems, as there is with any other new industry, and it is up to the members of that industry to figure out how is the best way to promote and market its services to the public, as well as to provide the public with assurance that their industry is open, honest, above-board, and adheres to the standards and ethics of any other business.

Medical tourism certainly has its pluses and minuses, and there are organizations (won’t name them here) that have not lived up to the expectations of the members of the medical tourism industry, and it is the duty of organizations like the IMTCC, and a new group that Christina told me about recently, called the Global Healthcare Travel Council, to correct the mistakes others have committed. The IMTCC is one of those organizations, and I thought it was vital that the workers’ compensation industry got to know them a little.

Lower Cost, High Quality Health Care is Nearby

My good friend, Amanda Haar, editor of the Medical Travel Today newsletter, where many of my blog posts have been published, reported this week on a Huffington article about the best havens for quality medical care overseas.

The article reported that the website,, recently released its 2013 Health Care Survey, which detailed the top eight countries for quality medical care. Of the eight mentioned by, five countries are in the Caribbean and Latin America region.

The five are: Costa Rica, Panama, Uruguay (new to me), Mexico, and Ecuador (also new to me).

While’s article focuses on medical care for expats who are taking advantage of the lower cost, high quality health care offered to the citizens of these countries, it is reasonable to assume that such lower cost, high quality health care can be available to medical tourists as well, including those covered under the US Workers’ Compensation system.

As the world gets smaller, and as more and more people move to the US in search of better opportunities, even during a slow economic recovery, the American workforce will be more reflective of the natives of these and other nations in the region, as I mentioned in my earlier post, “No Back Alleys Here”.

So if that is the case, and if the cost of medical care is rising, then shouldn’t we here in the US take advantage of the lower cost, higher quality health care for our injured workers that is obtainable abroad?

Five reasons virtual doctor visits might be better than in-person ones

This has tremendous potential for the medical tourism industry, because it will allow doctors overseas to communicate with US-based physicians and their patients before going abroad for medical care. There is one small problem, some states make it illegal to consult with a patient over the Internet after the patient goes home, and there are laws against doctors not being licensed in the states where the patient lives, as well as laws preventing foreign medical providers from doing certain procedures. It is imperative that these laws are changed before virtual doctor visits become more widespread.


In relatively few years, videoconferencing has advanced tremendously, from something that required expensive and complicated hardware setups to something most smartphone, tablet, and PC owners have easy access to. Using video for virtual visits in healthcare is a little more complicated — the connection has to be reliable and the service HIPAA compliant to protect patient medical information — but nonetheless virtual visits are gaining popularity as a new way to deliver healthcare.

Becky Wai, a spokesperson for online video service VSee, told MobiHealthNews on the sidelines of the American Telemedicine Association (ATA) meeting in Austin this week, that of the 900 million doctor visits that took place in the US in the last year, about 50 percent of them could have been done remotely.

Of course, virtual visits can’t do everything that a doctor can do in-person. But in the average primary care checkup, a patient sees a doctor…

View original post 973 more words

All’s Well that Ends Well

It’s kinda quiet in the work comp blogosphere, and I’ve written enough about the pain medication abuse problem, that I thought I’d write another little scenario in which medical tourism can be implemented into workers’ compensation.

Here it goes:

“Juan Herrero”, not his real name, is a hard worker. He moved to the US as a small boy and got married, found a job and raised three kids as an employee of a large utility company in the Southeastern US.

Juan is the kind of guy you often see on a cherry-picker, high in the air, fixing electrical lines and cables. One day, while Juan was working in the cherry-picker, the door to the cab opened, and Juan fell to the ground. Luckily, the cherry-picker had not reached all the way to the top, so Juan’s fall was not that far.

However, Juan did injure his back, his shoulder, and suffered some bumps and bruises when he landed on the ground.

Juan was immediately taken to a local hospital and was seen by an emergency room doctor, and a specialist in orthopedics and spinal injuries. As his injuries were not life-threatening, and it appeared that Juan had not needed emergency surgery, he was released and allowed to go home.

Over the next two weeks, Juan complained of pain as he rested at home under doctors’ orders and having already missed time from work. His employer filed a workers’ comp claim with their insurance carrier, and Juan began to receive his indemnity payments.

But as the insurance company’s adjuster was beginning to handle Juan’s claim, the adjuster realized that it may be necessary for Juan to have surgery on his back and his shoulder after all, because of medical reports the adjuster received subsequent to his release from the hospital.

The adjuster, who worked for a Third Party Administrator, realized that for their company to pay for Juan’s treatment, it would be a considerable cost that they were not willing to spend on this case.

As it happened, the adjuster had the foresight to remember an article he read about medical tourism to Latin American countries, where surgery was far less costly than what is charged in the U.S.

One of the responsibilities of the adjuster was to find the best care for the injured worker at the lowest possible cost, and when he realized that surgery could be thousands of dollars less than here in the U.S., plus the cost of airfare and accommodation for the patient and his spouse, the adjuster decided to approach his superiors and the insurance company, and the employer to see if they were willing to try this. They agreed, provided that Juan and his wife agreed to go abroad.

As Juan had come to the U.S. from Chile, the adjuster learned that there was a hospital in Santiago, Chile, that specialized in trauma and rehabilitation. The name of the hospital was Hospital del Trabajador. Trabajador is the Spanish word for working man.

Juan and his wife agreed it would be a good idea to go back to Chile and see old friends and relatives they have not seen in years. As their three children were old enough to be left with friends nearby, the opportunity to have a vacation was enticing.

Juan and his wife flew to Santiago, and were met at the airport by the hospital’s staff, who escorted them to transportation that would take Juan directly to the hospital. His room was waiting for him, and the nursing staff got him into bed as soon as possible.

Juan’s wife was very pleased with the hospital room, and with the accommodations, and his surgery went exceedingly well, as the doctors had planned. He had an uneventful recovery, and his Chilean friends and family came to visit him and his wife while he was recuperating from surgery and throughout his rehabilitation.

Juan returned home to the U.S. grateful that his employer, their insurance carrier, and the TPA had suggested medical tourism as a treatment option, and his wife and friends and family were glad that Juan received such wonderful treatment.