Category Archives: Immigration Reform

Immigration Reform Revisted

Tomorrow evening President Obama is to unveil his plan to grant millions of undocumented immigrants a form of legal status by executive action.

As reported in two articles today, one in Health Affairs blog, and the other in The New York Times, access to health care will not be a part of the President’s plan.

In “The Case For Advancing Access to Health Coverage And Care For Immigrant Women and Families”, Kinsey Hasstedt said that a web of policy barriers to public and private insurance options effectively keeps millions of immigrant women and their families from affordable coverage and the basic health care, including sexual and reproductive health services that coverage makes possible.

Of course, this sounds all too familiar to anyone who has read my articles in the past about immigration reform, medical tourism/travel, and its implementation into workers’ comp.

Ms. Hasstedt also said that many lawful immigrants are ineligible for coverage through Medicaid and CHIP (Children’s Health Insurance Program) during their first five years of legal residency. And as reported in today’s New York Times, undocumented immigrants are barred from public coverage, and the ACA prohibits them from purchasing any coverage, subsidized or not, through the exchanges.

In The New York Times article, Obama’s Executive Order on Immigration Is Unlikely to Include Health Benefits, the president will use his executive authority to provide work permits for up to five million people who are in the US illegally, and shield them from deportation. But his order will not allow them to be eligible for subsidized, low-cost plans from the government’s health insurance marketplace.

Ms. Hasstedt noted in her article that past immigration policy reforms, both executive (something the GOP forgot about because it was Saint Ronnie who did it) and congressional have failed to address the health care needs of immigrants.

I know there are many in the immigrant community, and among their supporters in the rest of the country who applaud the President for taking this long-overdue action due to the inaction of a Congress more in tune with the sentiments of those who like wearing white sheets, than a party whose last occupant of the White House preached “Compassionate Conservatism”.

And there are many within the Insurance and Risk Management and Workers’ Comp industry who downplay the impact immigration reform and the granting legal status to undocumented workers will have on the number of claims filed under workers’ comp.

But as I said in many previous posts, there is no way that workers’ comp can handle all of the claims that will be filed not only by legal residents, but by immigrants and those who are granted legal work status, as the President will do tomorrow night.

The medical tourism/travel industry is not perfect. Name me one industry that is. But the reality is that I have found, having attended three different conferences in the span of two years , that there are highly professional and dedicated people out there, physicians, hospitals and clinics who not only are seeking patients for private pay or group health insurance, but would probably consider taking on patients under workers’ comp, especially in the areas of orthopedic surgeries from work-related accidents, repetitive motion injuries such as Carpal Tunnel, and even weight-loss surgery, as I mentioned in my last post.

So while many in the industry are gambling in Las Vegas this week, which as the commercial says is where their money is going to stay, and where many Hispanics once called home before we showed up, it is high time to seriously consider medical tourism/travel as an option.

The influx of immigrants, and the soon-to-be announced legal status of the undocumented will put a terrible strain on an already strained health care system. It’s time to open the safety valve and let injured workers, many of them Latino, receive care in their home countries and in neighboring countries so that there are no language or cultural barriers to contend with.

Opening up a safety valve and immigration is nothing new. It’s how millions of Europeans came to America in the 19th and 20th centuries. I would not be here writing this today if my grandparents could not use the safety valve of immigration to escape what would have been a terrible fate. Thousands of Irish would have starved if they could not immigrate to the US and other countries. And millions of Chinese would have died in labor camps, famines and revolutions in the early 20th century.

But so long as the US workers’ comp system is locked away in a “padded cell”, the increased number of legal and undocumented workers with legal work status will add more demand on an already overburdened health care system.

The choice is yours. You can go with the flow of history, or stay in Las Vegas and party your way to irrelevance.

Primary Language-Speaking Physician Ruled Not Medically Necessary

I came across an interesting article today from David DePaolo on his blog, DePaolo’s Work Comp World. The article, Comunicación No Es Médicamente Necesario, discussed a recent workers’ compensation case in Florida that involved the right to bilingual treatment.

A roofer in 2012, suffered a head injury when he fell 30 to 40 feet off of a ladder. His employer accepted the compensability of the injury and authorized treatment from several doctors, including a neurologist, Dr. Angelo Alves.

Dr. Alves recommended that the claimant undergo a neuropsychological evaluation for his memory, cognition and emotional state. The employer then arranged an appointment with Dr. Arthur J. Forman. Because Dr. Forman did not speak Spanish and the claimant only spoke limited English, his employer arranged for an interpreter for the claimant’s office visits

The claimant objected to the interpreter, and filed a petition for benefits, seeking authorization for an evaluation by a Spanish-speaking neuropsychologist. His reasoning was that he did not want to do it through an interpreter and talk about the intimate details of his life through another person.

Dr. Alves supported the claimant’s claim and testified that the claimant needed to have a neuropsychological evaluation performed by a Spanish-speaking psychologist. It was Dr. Alves’ position that having the evaluation through an interpreter was not the same as with a Spanish-speaking doctor, because the doctor could get the wrong information.

However, the Judge of Compensation Claims was not persuaded by that argument. The claimant appealed, but a split panel of the First District Court of Appeals agreed with the JCC.

The finding of the court was that while a Spanish-speaking provider was preferable, the evidence did not establish medical necessity.

Judge Scott Makar, an appointee to the First District Court of Appeals by current Tea Party-backed Florida governor, Rick Scott, in a concurring opinion, addressed the challenges of meeting health care expectations within the limited resources of any health care delivery system.

According the Judge Makar, “In an ideal world with unlimited resources patients would have health care information published in their own primary languages, and their health care service providers would speak their primary languages.” He went on to add, that since this ideal is “unattainable”, “the trajectory of the language access movement in the United States currently has gravitated to the use of translators (for written communication) and interpreters.”

The dissenting opinion, by Judge Bradford Thomas, an appointee of former governor Jeb Bush (who by the way speaks Spanish and is married to a Hispanic woman), argued “that no medical testimony supported the JCC’s view that the Spanish-speaking psychiatric evaluation was not medical necessary, and that the JCC had failed to give a “reason” for rejecting Dr. Alves’ opinion.”

David pointed out that Judge Thomas had the burden of proof backwards and ignored the substantial evidence standard. But, he also pointed out that the majority opinion seemed to take the position that Spanish is a “minority” language, which David points out in the rest of his article, it isn’t.

Before I tackle that issue, I would like to explain why I mentioned who appointed the concurring and dissenting judges, and what struck me as I read the court’s ruling in this case. Had Judge Makar been appointed by any other governor besides Rick Scott, I would have been puzzled as to why they would go out of their way to annoy a growing segment of Florida’s population such as Latinos, especially since they are sensitive to any form of discrimination against their community, such as restricting their right to vote.  This is especially true of non-Cuban Latinos who generally vote for Democrats.

That Rick Scott is a Tea Party-backed politician, and knowing that the Tea Party has elements in it that despises immigrants, both legal and illegal, who are usually Hispanic, Judge Makar’s opinion shows obvious Tea Party bias towards Spanish-speaking people in the state.

His characterization of Spanish as a “minority” language is certainly not true to this former New Yorker who had gone through several areas of Miami, Fort Lauderdale and many other cities in South Florida and felt like I was in the minority. Also, his statement about an ideal world is typical of right-wing conservatives who are opposed to any accommodations to non-English speaking people.

I say this as the grandson of four immigrants who had to learn English and had to speak their native language, Yiddish, at home amongst themselves and other family members and friends, so that the “kinder” would not know what they were talking about. And since my family also came from what was once the Russian Empire, they had to know a smattering of Russian and maybe Polish to converse with neighbors and officials of the government.

But that was a different time in the US, when the National Civic Federation sponsored night classes in English to newly arrived immigrants so that they can assimilate. But it is different now with Latinos, and as has been pointed out before, the younger generation of Latinos already here, speak English and Spanish. I have had classmates in my MHA classes, and have met many others in all areas of South Florida who do.

On the other hand, Judge Thomas’s appointment by Jeb Bush did not surprise me, given his dissenting opinion. It recognizes the reality of life in Florida, and in other states, with regard to Hispanics, and does not, like the Tea Party often does, seek to turn the clock back to a time in the US when only one language was spoken.

Going back to David’s article, demographic research he points out, shows that the Hispanic population has outgrown that of the white population in David’s home state of California and New Mexico, as well as a few other states, according to a Pew Research Center study. The projections, David cites, are that these demographics will be reflected in the overall US population by 2040.

California has about 14 million Hispanics out of an overall population of 33 million. 47% of New Mexico’s population is Hispanic, and while the white population of Texas is still the majority that is projected to change soon, as the Hispanic population growth represents nearly 64% of all population growth since 2000.

Florida, by contrast, David states, has 4.5 million Hispanics, which represents 23% of the population. He notes that because workers’ compensation is state specific, relative to the overall population of the state, the decision by the First District Court of Appeals makes sense. However, that he says can change.

I have discussed the issue of immigration reform and its impact on workers’ compensation and medical tourism in earlier posts, and have cited statistics about the Hispanic population growth in such articles as Immigration Reform on the Horizon: What it means for Medical Tourism and Workers’ Compensation, Immigration and Workers’ Compensation: Round Two, and E PLURIBUS UNUM: Latin American and Caribbean Immigration, Workers’ Compensation and Medical Tourism.

It also occurred to me that the court that decided this recent case was the same court that decided an earlier case that I mentioned in Legal Barriers to Implementing International Providers into Medical Provider Networks for Workers’ Compensation: A White Paper.

In that case, AMS Staff Leasing, Inc. v. Arreola, FL 1st DCA, 2008, the First District Court of Appeals ruled that Arreola, who had been injured loading a truck, was entitled to get treatment in his hometown in Mexico.

The court ruled that “that state law did not preclude the foreign physician’s treatment of the claimant in Mexico. They stated that Florida workers’ compensation law contemplates coverage for non-citizens, and they cited an earlier case in which the court held that undocumented workers were entitled to workers’ compensation coverage in Florida…”

The court “also stated that Florida law indicates that an injured worker is not prohibited from moving from his pre-injury residence in the state, and receiving treatment outside of the state.”

This would appear to indicate that the court in 2008, before Rick Scott became governor, was willing to have workers’ compensation claimants get treated by physicians in their home country who could speak their language, but the court in 2014, with an appointee of Tea Party-backed, Rick Scott, ruled that the claimant in this case had no right to a physician who could speak his language, even if the claimant was seen here in Florida and not in his home country.

It would appear that judges appointed by Tea Party-backed governors, especially in a state like Florida, are trying to deny the rights of Hispanic claimants to Spanish-speaking doctors. Such a ruling in light of future increased Hispanic population growth is not only unconscionable, it smacks of racism and discrimination. But David DePaolo is correct in citing Bob Dylan’s song, “The Times, They Are A Changing.” Hopefully, future courts in Florida and elsewhere will correct this travesty of justice, and when medical tourism in workers’ comp becomes a reality, evaluations by Spanish-speaking physicians will be commonplace occurrences.

What A Long Strange Year It’s Been – My Year as a Medical Tourism Blogger

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Introduction

Today marks one year that I began my blog on medical tourism and its implementation into workers’ compensation.  From the beginning, I did not have any idea if my blog would be successful, or if it would be a complete failure. One year in, with over 8,000 views, and less than 100 followers, the jury is still out, so it remains to be seen where the blog goes in the next year.

Yet, just this month, on October 7th, I had 233 views (highest ever) and 205 visitors. But one thing is certain; I have had a very interesting time writing it, and have made some wonderful connections both in the medical tourism industry and out of the industry, from all over the world. But I have also had some rather disappointing experiences as well. This post then is a look back and maybe a look forward to another year of blogging, hopefully more rewarding, both career-wise and financially than this year coming to a close has been.

Why I started the Blog

I started the blog for three reasons: One, I had just attended the MTA Congress in Hollywood, Florida three days earlier, after they had published my White Paper on their website. The White Paper was too long for their online magazine, so they asked me if I would not mind it if they published as a White Paper. When I said yes, they eventually invited me to come to the Congress free of charge, for which I was very grateful, since I was unable to spend that much money to participate. After the Congress was over, I had learned from a few industry sources and two legal experts, that the MTA copyrighted my paper without my written permission, so I had one of the lawyers find me a template so that we could use to send them a letter asking them to either remove the copyright, and remove the Editor-In-Chief’s name from it, or remove it altogether and let me know in writing. They did remove the paper, but I had to find out for myself when I went to their website.

The second reason I started the blog was because of my MHA degree (Masters in Health Administration) which I received a year earlier, and for which I wrote the term paper that was the basis of the much longer White Paper. My Health Law class required a paper on a legal topic in Health Care, and since I had neither a legal background, nor a health care background, I went out to social media to find a topic. The first topic suggested to me did not yield much information and was not a good research subject, so again I went out to social media, and a lawyer in CA gave me the idea to write about the legal barriers to implementing international medical tourism into workers’ compensation. She helped with getting legal cases and some of the editing of the original paper, as well as some of the work expanding it into the larger White Paper. I was unsuccessful in getting any legal journals to publish it, so that is when I turned to the MTA.

The third and most important reason why I began my blog was to explore new avenues of employment in either medical tourism or in workers’ comp, or even health care. I did this because I felt my workers’ compensation and insurance experience, which consists of work in Auto No-Fault, Risk Management and Insurance Data Processing with regard to claims, brokerage and statistical reporting of workers’ compensation claims and policy data, would be valuable to organizations in those industries. Unfortunately, due to the economic downturn and jobless recovery, many companies have curtailed their hiring, and many are just filling jobs that require a finite set of skills and background that I do not possess. I have made connections both before my degree and after with executives in many companies, and in many parts of the US, but have gotten little or no response to my inquiries.

My career has been somewhat broad and varied, depending on the nature of jobs available at the time, but they have given me an insight into the world of insurance in general, and the world of workers’ compensation in particular, so after attending the Congress, and meeting different people from other countries, and hearing one company’s experience as a self-insured employer utilizing medical tourism for their employees on their health care plan, I thought that it might be possible to do the same for those employers who are self-insured for workers’ compensation, as well as those who purchase workers’ compensation insurance in the insurance market.

A Brief Review of Past Posts

My first post, on October 29, 2012 was a recap of what I learned at the Congress and what I thought about medical tourism as a viable alternative to high cost medical care in the US. The post, entitled, What I Learned at the 5th World Medical Tourism & Global Healthcare Congress, and Why It Matters to the Workers’ Compensation Industry, also discusses the three cases I cited in my paper which involved some form of medical tourism; either domestic medical tourism, or cross-border medical tourism,( i.e., Mexico), from CA and FL.

The third post I wrote was a shortened version of my White Paper, called Medical Tourism and Workers’ Compensation: What are the barriers? Here, I attempted to get the workers’ comp industry interested in the idea by giving them the highlights of my original paper. Almost immediately after I began blogging, my posts were picked up by other blogs and newsletters in the health care and medical tourism industries, and I am thankful for their faith in me as a blogger that they continue to do so.

As a further inducement to get some interest in the idea of implementing medical tourism into workers’ comp, I created a fictional case study about a self-insured employer who is self-insured for both health care and workers’ comp, but whose Risk Manager was unaware of how much money he could save if he followed what the Employee Benefits Manager was doing on the health care side with medical tourism. In the case study, A ‘Case Study’ in Implementing Medical Tourism into Workers’ Compensation, three workers sustained injuries while working at a job site and needed surgery that would have cost the company thousands of dollars. The Risk Manager told the Employee Benefits Manager about this, and learned that the company was sending its workers to countries in Central America for less expensive health care with better quality outcomes, and the Benefits Manager suggested he do the same with the injured workers.

The one topic that I have written the most about in the past year was about the impact of immigration reform on workers’ compensation, and subsequently, on medical tourism. The following posts were written because I came to believe that Latin America and the Caribbean was the most logical region of the world to pursue medical tourism, since it is so much closer to the mainland US and the workforce here is increasingly Latino and Caribbean.  These are the four posts:

The Stars Aligned: Mexico as a medical tourism destination for Mexican-born, US workers under Workers’ Compensation, Immigration Reform on the Horizon: What it means for Medical Tourism and Workers’ Compensation, Immigration and Workers’ Compensation: Round Two, Testimonial on Medical Tourism in Mexico.

The last post was supposed to be followed by even more testimonials, and may still be, but it will have to wait until after this one is posted. Finally, I decided that I should acquaint the workers’ comp industry with some of the medical tourism facilities that had booths at the MTA Congress, so I wrote the following post from literature I gathered during the last two days when the Exhibition Hall was open. No Back Alleys Here: Medical Tourism Hospitals, Clinics and Networks in Latin America and the Caribbean, simply listed the hospitals and clinics by country and listed the hospital’s websites, where available. It would be up to the reader, I felt to check them out.

What I have learned About Medical Tourism – The Good, the Bad, and the Ugly

My experience writing the blog has educated me about the medical tourism industry, even though I do not actually work in it at present. Perhaps being an outside observer gives me an honest and forthright perspective that many inside the industry don’t have, but in my email conversations with some of them, they are already aware of the nature of the beast, as it were, so here are my thoughts about the industry —the Good, the Bad, and the Ugly (with apologies to Sergio Leone, but not to “Mr. Talks-to -empty-chairs”).

The Good

In the past year, I have met some very nice and dedicated people who want to provide patients with quality health care, at affordable prices, plus a little extra on the side. Whether it was at the MTA Congress last October where I met people from Mexico, Guatemala (Belgian, actually), Australia, Singapore, China, Canada, Finland and the US, or online through my blog or my LinkedIn profile, I know that the medical tourism industry has very good promoters and patient advocates.

Many of the online connections I have made are in India, which is the primary destination for medical tourism. But there have been other connections made all across the globe from Europe, the Middle East, East Asia, Africa, and some from Latin America and the Caribbean. This proves to me that medical tourism is a growing and dynamic industry that will continue to grow, provided that it attracts the same kind of people I have connected with over the past year. Yet, as we shall see below, there is a grey cloud and a dark cloud over the industry, which threatens its long-term sustainability and growth…the bad and the ugly sides of medical tourism.

The Bad

Any industry and any business in that industry must be able to not only justify its existence, but to prove its value and worth to the customer, and medical tourism is no exception. So, it has been disheartening to me that I have been unable to get exact cost figures for certain surgeries that are common to workers’ compensation from some medical tourism facilities in Latin America and the Caribbean, as I described in my post, If You Have to Ask…Fuggedaboutit!.

In that post, I said that transparency on costs was vital if the medical tourism industry wanted to pursue business in the American workers’ compensation industry, because employers, insurance companies, and third party administrators will want to know up front if this is really a less expensive alternative to high-cost surgery in the US. I even cited surgical costs from some countries in the region, and some costs from Asian countries that I originally cited in my White Paper. These last figures, I have been told by some people are not accurate and therefore, are only a guesstimate of the actual costs.

In addition, I have been told that figures on the number of Americans going abroad for care are inflated, often because they count expatriates who are living and working in those countries as patients, besides those who actually did travel abroad for treatment, so again here is another area where transparency is needed.

Finally, as I point out in my post, Ensuring Patient Safety: Making Sure Medical Tourism Puts Its Money Where Its Mouth Is, patient safety and quality are also important areas where transparency must be observed if the medical tourism industry is to be more than just a rich man’s game. You have to prove to all stakeholders in the care and treatment of patients, and even the patients themselves, that you have equal or better quality outcomes than what is available in the US, and that patient safety, like costs and numbers of treated patients, are presented upfront and clearly to all interested parties. Failing to do so will only drag down the growth of medical tourism, and may even give it a black eye from which it may never recover.

The Ugly

As in any endeavor, individuals are bound to find detractors who critique and even attack you for your beliefs and for your efforts. I am no exception to that, and have received my share of critiques and attacks during the past year. I answered these critics in the following two posts, The Faith of My Conviction: Integrating Medical Tourism into Workers’ Compensation is Possible and is not a Pipe Dream, and Clearing the Air: My Defense of Implementing Medical Tourism into Workers’ Compensation.

I am not going to rehash this issue here again, but only bring it up as one part of what I see as the ugly side of medical tourism. There is too much personal animosity among certain individuals and organizations, especially in an industry that is still in its infancy. And while I have accepted an apology from one of my critics, there are still some ugly and vile behaviors that have been perpetrated against well-meaning and decent people who just want to grow this industry from the bottom up, instead of from the top down. There is no reason why people have to be nasty to each other, there is enough business on this planet of seven billion to go around.

Any organization that purports to represent the interests of an industry at large, and whose executives claim to be reputable spokespersons for that industry, must not engage in childish and unprofessional behavior that casts doubt on the individuals involved, the organization they belong to and the industry as a whole.

Holding fancy conferences around the world and charging big numbers only to see a handful of attendees actually paying and the rest being invited or begged to attend, does not suggest a healthy and vibrant industry, nor does it show that the leading organization promoting that industry is a trustworthy and honest one.

What I have not gotten from both industries

Medical Tourism industry

Perhaps it is because many in the industry have a background in general health care, or perhaps it is because they have experience in the travel, wellness and resort industries, that many of the people who have connected with me are not familiar or aware of what potential the US workers’ compensation market can be. I have received many offers of partnerships with these individuals, but I have to point out to them that I am not a doctor, I am not a medical tourism facilitator, nor do I have any other business that would partner with them in such an endeavor, and therefore, cannot refer patients to them.

Naturally, I thank them for considering me, but given that many of them are in Asia, and I am focusing on Latin America and the Caribbean, there is no reason for me to explore it. I would, however, like to hear from some organization or company doing business in that region who is seriously considering entering a new market such as workers’ compensation, given the increase in the Hispanic and Caribbean workforce in the US. That region has many “rising stars” in the medical tourism world, and can be very lucrative if the right people recognize its potential.

In addition, the newsletters and blogs that have re-posted my posts have for the most part, not generated much feedback or comments, and I wonder if anyone besides the publishers and their staffs are reading them. My own blog publishing site, WordPress.com, has garnered me nearly 10,000 views since I began blogging, but again, the response has been rather weak.

Workers’ Compensation industry

As I stated above, the most important reason why I began the blog was to simply find a job in the workers’ compensation industry after spending two years in school getting my MHA degree and looking for work after the recession and jobless recovery following the events of 9/11, the housing bubble that burst in 2007, and the financial collapse of 2008. The problem that I and many others are facing is that the industry is shrinking and companies are being bought by either their competitors, or by private equity firms, such as what just was announced recently when a company called Apax Partners bought One Call Care Management (OCCM), a workers’ compensation services company in a multi-billion dollar deal.

In May, I had lunch with one of OCCM’s Regional Sales Directors who shares my idea about medical tourism and workers’ compensation, and who thought we might be able to put something together that would address his clients’ concerns about the high cost of surgery. His company provides transportation, translation, home care equipment and medical devices to the work comp industry, and even has an in-house travel agency, which would make them the ideal medical tourism facilitator for workers’ compensation patients.

After several phone calls that ended without any further action on our parts, I decided to contact the top management of his company, even sending my White Paper and resume to the Chairman of the company and the President and CEO. That was back in September, and one month later, I have not heard from either of them.

I learned recently that because of this deal, it is unlikely that the President of the company will do anything with my idea. That seems to be the case with many other companies, and why I have gotten no traction with my idea from anyone else in the workers’ comp industry. When I post my blog posts on social media, it is like they are falling on deaf ears, or in this case, blind eyes. They seem to more concerned with being bought up, dealing with the opioid issue, or the physician dispensing issue (which is related to the opioid issue), or they just don’t see this as a viable alternative because they are too conservative and too cautious, and too willing to do the same things over and over again and expect different results. That, as I said before in a more recent post, is The Definition of Crazy.

Predictions

Making predictions nowadays is a little like knowing what Ted Cruz is going to do next for an encore; they’re unpredictable and designed to make the person doing so look good, so to spare you and me from any embarrassment, let me just add that health care is changing, and the direction that it takes will depend a lot on what has already happened, and what is currently happening, especially in light of the problems with the ACA rollout earlier this month.

But my recent post, Ten Years On: One Person’s View of Where the Medical Tourism Industry will be a decade from now, spells out some of the things that may influence the direction medical tourism takes in the future. Hospital costs, outpatient costs, consolidation of hospitals, cost to employees, immigration reform and technology will all play a role in determining the direction medical tourism takes in the next ten years and beyond.

Conclusion

As I begin a new year of blogging, I am grateful for the opportunity to provide my readers with new knowledge and insights to different topics, ideas and issues that affect not only workers’ compensation, but all of health care, medical tourism included. I hope that my writing has made many of you stop and think and look at things in a different light. I also hope that you have been entertained by my writing, as far as a serious subject can be entertaining when it pertains to human life.

But most important, I hope that this next year will provide with me everything I had hoped the last year would have; a new position, recognition of my idea as a viable alternative to high cost health care for workers’ compensation, and greater opportunities to personally interact and meet so many of the people engaged in the medical tourism industry around the world.

Here’s to a better blogging year!

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Thank you so much,

Richard

Ten Years On: One Person’s View of Where the Medical Tourism Industry will be a decade from now

Author’s Note: The following article was written last May for a Medical Tourism publication that requires original content, so I have not posted it to this blog until now. It was recently brought to my attention that they may not be around much longer, so that is why I am posting it at this time.

In these uncertain times, it is difficult, if not impossible, to predict from one minute to the next, one day to the next, one month from the next, or one year to the next, how any industry will grow and what its future will look like. So to predict where one sees the medical tourism industry going in the next five to ten years is anyone’s guess. But there are a few key indicators of what might happen if certain trends hold true.

In my first six months of blogging about medical tourism and workers’ compensation, I have found three key indicators of where the industry might go if the trends they signal continue for the next five to ten years. These indicators are costs, immigration reform, and technology. The cost indicator can be further broken down into its component costs, i.e., in-patient hospital costs, outpatient services costs, consolidation of US hospitals which lead to higher costs, and costs to employees covered under their employer’s health care plans, as more employers shift the burden to the employee.

There may be other costs that will affect the medical tourism industry’s growth in the next decade, but the costs listed above have a more immediate effect because they impact patients more than they impact the health care system at large. While it is true that hospital costs will impact everyone, the patients will experience it more because it may limit them to choosing certain hospitals that charge less for the treatments they require, but at lower quality of care. There will always be one hospital that charges the most and one that charges the least, so the patients may be forced to choose between one, and the other.

This article will outline some of the things I think will determine the future of the medical tourism industry, and is based on my knowledge of the US healthcare system and my workers’ compensation background. It is by no means an exhaustive inquiry into the future of medical tourism, but it is hoped that the reader will get a better idea of the state of the industry in the years ahead.

Costs

Hospital Costs

As I reported in my blog article, Rising Hospital Costs: What they mean for Workers’ Compensation and Medical Tourism, workers’ compensation carriers were noticing that their bills and payments to hospitals for inpatient and outpatient services were increasing significantly faster than other costs. I cited a report from the Workers’ Compensation Research Institute (WCRI) that shows that facility costs were up in several states, including Indiana, which was the focus of the report. The WCRI reported that Indiana’s costs were substantially higher than the median states WCRI mentioned in the report. This increase was driven by prices. Indiana, which does not have a fee schedule for facilities, means hospitals there can raise prices whenever they want, and are doing so.

The WCRI also reported that overall hospital payments per stay increased 12% per year from April 2005 to September 2010. At that rate, workers’ compensation carrier’s costs will double every six years. In addition, an article in the New York Times on December 18th, 2012, that stated that hospitals are likely to get huge cuts from the fiscal cliff deal, and that Medicare cuts will target hospital reimbursements.

At time I wrote that article, I predicted that as far as medical tourism is concerned, in-patient services were where the industry will have the greatest opportunity to address this problem. Rising US hospital costs may force US workers’ compensation carriers to look for lower cost, better quality health care services for their insured’s injured employees, something which medical tourism is already offering the private insurance market in the US.

Outpatient Costs

Sometime after I wrote about increasing in-patient hospital costs, I wrote another article about outpatient services costs entitled, Outpatient Facility Costs Rising Could Benefit Medical Tourism Industry. In that article, I reported that the Workers’ Compensation Research Institute had released another study that analyzed the outpatient facility costs, cost drivers, regulatory mechanisms, and trends in 20 states.

The report, found that:

  • States with no fee schedule regulation on reimbursement had higher hospital outpatient/ASC (ambulatory surgical center) costs than states with fee schedules.  The costs in states without fee schedules were 27 percent to 73 percent higher than the median of the study states with fee schedules.
  • States with fee schedule regulations that were based on a percentage of charges had higher costs compared to states with other types of fee schedules, such as per-procedure based or ambulatory payment classification (APC) based fee schedules, with the exception of Illinois.
  • After fee schedule changes, growth in hospital outpatient/ASC costs resumed at faster rates in states with fee schedule regulations that were based on a percentage of charges.
  • Significant variations in hospital outpatient/ASC costs were also found across states.  Compared with the 17 state median, the average hospital outpatient/ASC cost per surgical episode in Massachusetts—the state with the lowest costs—was 60 percent lower than the median study state, while the average cost in Illinois—the state with the highest costs—was 45 percent higher, as of 2009.

I also stated that as facility costs rise in these 20 states, due to changes in Medicare and Medicaid hospital reimbursements, cheaper, more cost-effective forms of treatment will become valuable to the payers who are now looking at higher facility costs, even for outpatient services.

I predicted then that should costs rise too much for even most workers’ compensation payers to pay, alternatives in medical tourism will be more and more attractive, especially for more serious cases, and perhaps, for those that otherwise would have been treated on an outpatient basis domestically.

To take advantage of this increase in outpatient costs, medical tourism facilitators should factor in the cost of treatment, travel and accommodation expenses, so that medical tourism could compete quite favorably with US hospitals in these states, and others, where facility costs will have skyrocketed out of control.

Consolidation of US Hospitals leading to higher costs

The consolidation of hospitals across the US had led to higher healthcare costs from higher hospital spending, according to a blog I cited in my blog post, Consolidation of US Hospitals Lead to Higher Costs and Reduces Quality.

The blog I mentioned in my article stated that hospital spending is the key driver of healthcare costs in the US and has been growing at nearly 5% year over year. One cause of this consistent increase in spending is the continuing consolidation of hospitals around the country.

This increase in consolidation, has given some merged hospital systems oligopoly power to impose fees that are far higher than those found in areas with high market competition.  Statistics show that hospital consolidation in highly concentrated markets have driven prices up by as much as 40%.

Because they have increased market power and leverage, hospitals charge private payers higher prices and are more successful in “cost-shifting” as a result of providing underfunded care. Studies show that stand-alone and community hospitals typically receive payments from private payers which are closer to Medicare/Medicaid fees.

Some of the impacts to cost and quality are as follows:

  1. Increases the price of hospital care.
    Increases in price due to hospital consolidation are largely passed onto consumers through higher premiums, higher deductibles/co-pays and even lower wages.
  2. Reduces quality of care, through decreased market competition.
    The focus of hospital consolidation is on reducing competition to increase market bargaining power when dealing with insurers. This reduction in competition also has an impact on quality and patient choice. Consolidated hospital systems may be less motivated to offer innovative, efficient methods and improvements to care quality in order to attract new patients.
  3. Consolidation hasn’t led to lower costs or improved quality.
    Integration of merged hospitals may lead to enhanced performance through achieving efficiencies, greater coordination and revising processes to unify entities. Consolidation alone only combines multiple entities under one group to increase market power, not necessarily fusing them together for improvement.

This is another area of costs that will have a definite impact on the future of the medical tourism industry, because hospital consolidation shows no sign of slowing down or halting altogether. And as we shall see in the next and last cost category, the impact of ever increasing costs in health care in the US will eventually lead to the one sector of healthcare that will suffer the most — the patient.

Cost to Employees

Up to now, I have discussed the impact higher costs may have on the future of the medical tourism industry in the next five to ten years. However, many of these costs will be borne by payers, not by the patients themselves. Where the trend in increasing costs does indicate that patients will be affected is in a survey released recently by the US health insurance company, Aflac, famous for its Aflac duck commercials.

The Aflac survey revealed that employees were not prepared for increased costs, and may not want control of their options, and that they lack the education about what is meant by “consumer-driven health care.”

The report finds that employees are not financially prepared, and that:

  • Only 24% of workers completely agree or strongly agree they will be financially prepared in the event of an unexpected emergency or serious illness.
  • Further, 46% of employees have less than $1,000 to be able to pay for out-of-pocket expenses associated with an unexpected serious illness or accident, and 25 percent of employees have less than $500.
  • Four-in-ten (40 %) of workers would have to borrow from their 401(k), friends and family to pay for out-of-pocket expenses associated with an unexpected serious illness or accident; 28 percent would have to use a credit card.

The report also states that:

  • Nearly three-quarters (72%) of the workforce have not heard of the phrase “consumer-driven health care;”
  • More than half (54%) of workers would prefer not to have greater control over their insurance options because they don’t have the time or knowledge to effectively manage it;
  • 62% of workers believe the medical costs they will be responsible for will increase, while only 23 percent are saving money for potential increases;
  • 75% of workers said they think their employer would educate them about changes to their health care coverage as a result of reform, but only 13 percent of employers said educating employees about health care reform was important to their organization.

Lastly, the report found that among consumers of health care plans:

  • 32% are not very/not at all knowledgeable about health savings accounts (HSA)
  • Three out of four (76%) are not very/not at all knowledgeable about federal and state health care exchanges
  • Almost half (49%) are not very/not at all knowledgeable about health reimbursement accounts
  • 25% are not very/not at all knowledgeable about flex spending accounts (FSA)

The net result of this is that cost-shifting from employer-sponsored health care plans to workers’ compensation will hasten the day medical tourism is implemented into workers’ compensation, so that employers and carriers can take advantage of the lower costs of medical care abroad.

There is no doubt that health care costs are rising and will continue to rise in the foreseeable future. The Affordable Care Act (ACA) was enacted to reduce costs, but many critics of the law believe that it will do the opposite. Only time will tell if these critics are right. In the event that cost do rise, the medical tourism industry must be ready to meet the challenges that higher costs present to the American people.

Immigration Reform

Immigration reform would seem like a very unlikely indicator of what the future of medical tourism will be, but it needs to be addressed for the purposes of implementing medical tourism into workers’ compensation. Since the end of the US election last November, both political parties, the Democrats and the Republicans, have been involved with staking a position on comprehensive immigration reform.

The majority of Democrats have backed efforts to reform the American immigration laws, while half of the Republicans in both houses of Congress, and a considerable portion of their electoral base, opposes immigration reform. The results of the Presidential election brought home one clear fact, the demographics of the US is changing, and the growth of the Latino community is a part of that change. So it behooves a political party that wants to be viable in the future to support immigration reform. The party that refuses to do so, does at their peril.

In Immigration Reform on the Horizon: What it means for Medical Tourism and Workers’ Compensation, I focused on the report by the Independent Insurance Agents & Brokers of America, Inc. (IIABA) and the Pew Hispanic Center, that stated there are probably 11 to 12 million undocumented immigrants in the US, depending upon how many “self-deported” due to the current US economic slowdown, of which demographically, this represents 5.4 million men, 3.9 million women, and 1.8 million children. In addition, there are 3.1 million children who are US citizens having been born here (64% of all children of the undocumented) from one or more parent.

I also mentioned that the report stated that out of the total number of undocumented adults, 9.3 million, 7.2 million (77%) are employed and account for around 5% of the US workforce. They comprise a disproportionate percentage in some industries, such as 24% of farm workers, 17% of cleaning workers, 14% of construction workers, and 12% of food preparers. These industries are some of the more typical industries where workers’ compensation claims are filed from.

Within a particular industry, undocumented workers comprise a higher percentage of more hazardous occupations, e.g., 36% of insulation workers and 29% of all roofing employees are estimated to be undocumented. Undocumented workers are entitled to workers’ compensation benefits in thirty-eight states, and many states place certain restrictions on whether or not undocumented workers can get benefits, or under what circumstances.

In addition, I pointed out an earlier post I wrote about Mexico as a destination for medical tourism for Mexican-born US workers, and I believe that as this issue gets closer to being solved, the likelihood will increase, that injured workers from Mexico and other countries in Latin America and the Caribbean, as well as native born American workers’, will travel to medical tourism destinations in the region, provided the workers’ compensation industry goes along with it.

Technology

You would not think that technology has anything to do with the future of medical tourism, but then you would be a modern day Luddite. Technology is revolutionizing many facets of life, and health care is a part of that. Electronic medical records, advances in imaging systems, and a host of other medical devices are changing the way health care is delivered.

But there are other ways technology is changing health care, and that will have a profound effect on medical tourism. In my White Paper on the barriers to implementing medical tourism into workers’ compensation, I mentioned several laws that prevent physicians from consulting with patients through the internet or over the phone. This may seem silly given the communications revolution, but it is a product of what happens when technology outstrips the laws we enact.

But the invention of the pc, tablet and the smartphone means that doctors and patients can be far away, and yet be in touch, and more importantly, doctors can access your medical records and consult with other physicians through such devices. A blog I follow recently reported on these devices and how they will make a visit to the doctor not just a personal one, but a virtual one. I re-posted this to my blog last week

What this will mean for medical tourism is that before a patient goes abroad, either the patient or their local physician will be able to discuss the case with the physician at the medical tourism facility, and that the physician overseas will be able to access the patient’s records while consulting with the patient or the local physician.

This will provide confidence to the patient that the treating doctor understands the patient, knows what treatment they are seeking, and will assure that the patient will have a better experience than if they simply went to the facility without first having any contact with the treating physician. It will also mean that both physicians can collaborate on treatment and aftercare, so that the patient can have a positive outcome. Medical tourism facilitators, insurance companies and even employers will be aware that the patient’s needs are being met because of the ease of communication technology provides.

Some observations on the current state of the medical tourism industry

Before I conclude this discussion of the future of the medical tourism industry, I’d like to make a few observations that have concerned me for some time, and that must be addressed if the future of the industry is to be a bright and rewarding one for all participants.

I am well aware that the medical tourism industry is still, as some have called it, a “cottage industry”. But it is a growing industry, and one that can ill afford to have petty jealousies, petty politics, and downright nastiness as a way of doing business. I am aware of individuals and organizations who have acted in less than honorable ways that cause more harm to the industry as a whole than it does to their own reputations. One can only imagine if other industries acted this way, where they would be, both financially and organizationally.

There are nearly seven billion people on this planet, and while it is likely not all of these seven billion will ever leave their home countries for medical care, the millions that will deserve a medical tourism industry that works harmoniously for the benefit of all patients. It is incumbent upon the medical tourism industry to act like responsible adults and treat each other with respect and cooperation, rather than with enmity and suspicion. There is plenty of business for all involved, so that the term “cut-throat competition” should not be taken literally.

Another observation I want to make is lack of transparency on costs of surgical procedures. Earlier this year, I wrote about some of the hospitals and clinics in the Caribbean and Latin America region from marketing brochures I got from the 5th World Medical Tourism and Global Healthcare Congress in October 2012. In trying to get more information for specific hospitals in some of these countries, I have had no success in getting information from the contacts I made at the Congress, or from individuals I have connected with through social media.

If medical tourism is to be taken seriously as an alternative to higher medical costs, especially here in the US, and more specifically, with regard to costs for workers’ compensation injuries requiring surgery, knowing how much a knee operation in Mexico, Costa Rica, Guatemala, Brazil, or other regional destinations, costs is very important. In light of the recent revelations by CMS of hospital charges in the US, where for example, spinal fusions range anywhere from $19,000 to more than $470,000, medical tourism destinations should be more than willing to produce an up-front range of costs for these and other procedures. This will go a long way to making medical tourism more open to all. Also, it will allow comparisons to be made, so that the choice to implement medical tourism into workers’ compensation can be made by employers, insurance companies, third party administrators, and maybe even the patients themselves, if provided with sufficient data to consider.

Transparency and a more cooperative and non-adversarial industry culture will mean that medical tourism will not just be a niche market, but a viable alternative for medical care. If I want to know how much a knee replacement or repair costs in Argentina, Brazil, Costa Rica or anywhere else in the Caribbean and Latin America region, so I can compare them to costs for the same procedure in the US, India, Singapore or Thailand, I should be able to do so easily, without having to go through hoops to get them.

Conclusion

The future of the medical tourism industry depends upon many factors, some it can control, and others it cannot. My purpose here was to try to examine some of the factors that the industry does not control and that may have a positive impact on the industry in the next five to ten years.

We examined the issue of the cost of medical care from its various components. We saw that hospital costs, outpatient costs, the consolidation of hospitals and the cost to employees are all going to impact the future of medical tourism.

We also looked at the likelihood that immigration reform in the US could mean that medical tourism may one day be implemented into workers’ compensation as more undocumented workers achieve legal status and can opt for treatment in their home countries if injured on the job.

And finally, we looked at where technology was going and how it will be possible for medical records and information to be transmitted through smartphones, making it more likely that medical tourism will be a viable option and that the treatment a patient receives is based on the most up-to-date medical records available.

So in closing, I think the future of the medical tourism industry is a bright one, so long as the industry can come together and work out its problems and can expand beyond being a rich man’s game. The other factors I mentioned above will only be important once the industry has shaken off its past and holds its head up high and steps up to the plate to provide better quality healthcare at lower prices for all patients, individuals, group health plan members and injured workers.

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Richard

Muy por delante de la multitud

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El título del post de hoy viene de un blogger que todos están familiarizados con estas alturas, Joe Paduda. Joe me dio algunos comentarios el otro día en mi post Lecciones, y al tratar de averiguar cómo llamar a este post, me pareció que éste era un título apropiado, porque he sido siempre muy por delante de la multitud en el tema de la medicina el turismo y la indemnización de los trabajadores, y sobre el tema del post de hoy, que es América Latina.

Uno de mis muy buenos editores, Shanti Nair, en Malasia, me envió un enlace a un comunicado de prensa el SBWire.com titulado “América Latina se convirtió en primer destino de turismo médico”. Otro artículo que encontré en Viajes y Turismo World.com, llamado “turismo médico Boom Testigos de América Latina”, se hace eco de la liberación SBWIRE, pero va un poco más en detalle.

Ambos artículos se analiza un estudio realizado por IPK International, que reveló que aproximadamente el 3 por ciento de la población mundial viaja para el tratamiento médico a los países extranjeros, y ambos se apuntaron a un paciente más allá informe Fronteras, dijo que la industria del turismo médico es un año $ 40 mil millones negocio. (Esto no ha sido confirmado por mí, así que sería mejor que verlo con PBB)

Según el artículo de Viajes y Turismo, el impulso detrás de viajar para recibir atención médica en el extranjero, por lo que se refiere a los EE.UU., está más allá de ahorrar dinero. La comunidad latina se siente atraído por esta, ya que les ofrece la paz de la mente en el tratamiento de los médicos de habla española e instalaciones de calidad. [Énfasis añadido]

Varias cirugías se realizan ahora en México, Costa Rica, Colombia, Argentina y El Salvador. Pacientes sin Fronteras informó que México ahora atrae cada año a más de un millón de pacientes, muchos de los cuales provienen de California, Arizona y Texas, y son principalmente hispanos.

Es la proximidad de América Latina a América del Norte, que hace que el turismo médico tan atractivo, un punto que he estado haciendo desde hace algún tiempo. Otros factores incluyen tasas favorables de cambio, el personal de salud bilingües, culturas amable, climas tropicales, y como he mencionado antes, las barreras culturales más bajos que proporcionarán un período de recuperación relajado, con amigos y familiares en los países que pueden visitar al paciente mientras se recuperaba.

Viajes y Tour Mundial también figuran destinos populares en América Latina, tales como: Costa Rica, Panamá, México, Brasil y Colombia.

Aquellos de ustedes que han estado leyendo mi blog desde hace algún tiempo se nota que he mencionado estos países antes, así que no viene como una sorpresa para usted que estos son los más populares destinos de turismo médico.

Volviendo al título de esta pieza, tuve una conversación de correo electrónico que se ejecuta con Joe ayer por la mañana antes de que tuviera que dejar para un funeral, y el resultado de nuestra conversación fue que la industria de la compensación de los trabajadores no cambia a menos que se ve obligado a cambiar. Mi respuesta a eso fue que la industria tendrá que cambiar si quiere o no, y si le gusta o no, no por mí o mi forma de escribir, sino porque como se puede ver en el mensaje que acompaña a éste, el población de los EE.UU., y la mano de obra es cada vez más hispanos, y hacer caso omiso de su deseo de buscar atención médica en el extranjero en su país de origen, no sólo es caro, ya que los costos son más bajos en estas instalaciones, pero también es contraproducente, en que los mejores resultados y los empleados más felices serán el resultado de aplicar el turismo médico en la compensación de los trabajadores.

Y en cuanto a estar muy por delante de la multitud en este tema, tengo que decir que me siento orgulloso de ser hasta ahora en frente de la multitud, si la futura fuerza laboral de los EE.UU. va a ser más hispanos, pero también me quedo con las ganas que la industria de la remuneración de los trabajadores es lo que va detrás de lo que el resto del mundo está haciendo. La atención médica no se detiene en el borde del agua, y tampoco deberías compensación para trabajadores.

Sí, es un tema complejo, que es otra cosa Joe mencionó a mí, pero eso es porque hemos hecho así. David DePaolo, que escribí el otro día, así lo dijo hace un tiempo, y creo que tiene razón. Hemos dedicado más esfuerzo en tratar con abogados, proveedores, pagadores, proveedores de servicios, etc, y hemos olvidado lo que la compensación de los trabajadores se trata. Se trata de la demandante / paciente, y no debemos pensar en lo que es mejor para ellos, y lo que quiere hacer?

Cuidado, los trabajadores un borrador, el cambio viene, y será mejor que a bordo.

Translated by Google Translate

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Me gustaría llegar a conocerte mejor, así que por favor rellene el formulario abajo y quiero saber quién eres, de dónde eres, y lo que me gusta de mi blog.

Muchas gracias,

Richard

Far In Front of the Crowd

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The title of today’s post comes from a blogger you are all familiar with by now, Joe Paduda. Joe provided me some feedback the other day on my Lessons post, and while trying to figure out what to call this post, I felt that this was an appropriate title, because I have been consistently far in front of the crowd on the issue of medical tourism and workers’ compensation, and on the subject of today’s post, which is Latin America.

One of my very good publishers, Santhi Nair, in Malaysia, sent me a link to a press release on SBWire.com entitled, “Latin America Becoming Prime Destination for Medical Tourism”. Another article that I found on Travel and Tour World.com, called “Latin America’s Medical Tourism Witnessing Boom”,echoes the SBWire release, but goes a bit more into detail.

Both articles discuss a survey conducted by IPK International that revealed that roughly 3 percent of the world’s population travels for medical treatment to foreign countries, and they both pointed to a Patient Beyond Borders report that stated that the medical tourism industry is a $40 billion a year business. (This has not been confirmed by me, so it would be best to check it out with PBB)

According to the Travel and Tour article, the impetus behind traveling for medical care abroad, as far as the US is concerned, is beyond saving money. The Latino community is attracted to this because it affords them peace of mind in dealing with Spanish-speaking doctors and quality facilities. [Emphasis added]

Various surgeries are now performed in Mexico, Costa Rica, Colombia, Argentina, and El Salvador. Patients Beyond Borders reported that Mexico now attracts more than a million patients a year, many of whom come from California, Arizona and Texas, and are mainly Hispanic.

It is Latin America’s proximity to North America that makes medical tourism so attractive, a point I have been making for some time. Other factors include favorable exchange rates, bilingual healthcare personnel, friendly cultures, tropical climates, and as I have mentioned before, lower cultural barriers that will provide a relaxed recovery period, with friends and family in those countries able to visit the patient while recuperating.

Travel and Tour World also listed popular destinations in Latin America such as: Costa Rica, Panama, Mexico, Brazil and Colombia.

Those of you who have been reading my blog for some time will note that I have mentioned these countries before, so it does not come as a surprise to you that these are the most popular medical tourism destinations.

Getting back to the title of this piece, I had a running email conversation with Joe yesterday morning before I had to leave for a memorial service, and the upshot of our conversation was that the workers’ compensation industry does not change unless it is forced to change. My reply to that was that the industry will have to change whether it wants to or not, and whether it likes it or not, not because of me or my writing, but because as you will see in the companion post to this one, the US population, and the workforce is becoming increasingly more Hispanic, and to ignore their desire to seek medical care abroad in their home countries, is not only expensive, given that costs are lower in these facilities, but it is also counter-productive, in that better outcomes and happier employees will result from implementing medical tourism into workers’ compensation.

And as for being far in front of the crowd on this issue, I have to say I am proud to be so far in front of the crowd, if the future workforce of the US is going to be more Hispanic, but I am also disappointed that the workers’ compensation industry is so far behind what the rest of the world is doing. Medical care is not stopping at the water’s edge, and neither should workers’ compensation.

Yes, it is a complex issue, which is something else Joe mentioned to me, but that’s because we have made it so. David DePaolo, who I wrote about the other day, said so a while back, and I think he is right. We have spent more effort on dealing with lawyers, providers, payers, service providers, etc., and have forgotten what workers’ compensation is all about. It’s about the claimant/patient, and shouldn’t we think about what is best for them, and what they would want to do?

Watch out, workers’ comp, change is coming, and you’d better get on board with it.

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Richard

Testimonial on Medical Tourism in Mexico

Here is a comment from a plan administrator in California that is so positive about medical tourism, that I had to share it with the blog readers and with those who read my posts from LinkedIn.

I administer a plan serving farmworkers, mostly in California, predominantly Mexican and Mexican American, predominantly Spanish speaking. We have long used providers of medical and dental services and some pharmacy services on the border in Mexico at negotiated rates well below US rates. One thing I noticed a couple of years ago – at a large travel convention in Los Angeles next to the meetings I attended there were two booths – one from Mexicali Tourism Board or Bureau and another from Tijuana. Both had several hotels – on both sides of the border promoting that they would provide transportation to and from various medical facilities – in other words, the medical providers and the lodging businesses were allied in promoting medical tourism to their respective areas. Later at a meeting in Palm Desert I ended up sitting next to a woman representing hotels in the Palm Springs area and suggested she may want to talk with the providers in her area about a similar marketing promotion. I agree that obtaining more transparent pricing from providers is critical – but it really is not that difficult to negotiate – at least with the Mexico based providers we have dealt with. My dominant population often prefers to travel to Mexico just for medical services – partly for the financial savings but also for “peace of mind” reasons – the providers speak the language, may have served them or family and/or friends in the past and there is a much greater sense of ease in such circumstances. I think US employers will find it worth the time to consider medical tourism options.