Category Archives: Legal Barriers

WA State Considering Telemedicine Legislation for WC

Legislators in Washington State are considering a bill, S. B. 5355, that would require the state’s Department of Labor & Industries to pay for telemedicine sert d require the department to provide access to telemedicine and reimburse providers for health care services provided to injured workers through such services.

The bill defines telemedicine as follows, according to the article, “the use of interactive audio and video technology, permitting real-time communication between the patient and the provider. ” It would exclude audio-only telephone calls (my White Paper mentioned this as a legal barrier to implementing medical travel into workers’ comp), fax messages, or emails.

Should this become legal, telemedicine services provided by hospitals, rural health clinics, physician offices, community mental health centers, and skilled nursing facilities would be covered.

This would have a profound impact on implementing medical travel into workers’ comp in Washington State, as this is one of two states that allows patients to travel outside the state or outside the country for medical treatment.

The Department of Labor & Industries has a page on their website called “Find A Doctor” where they list physicians in both Canada and Mexico, as well as the rest of the US, and when I began my research for my paper back in 2011, had a list of physicians in the following countries:  England, Germany, Honduras, New Zealand, the Philippines, Spain, Thailand and Ukraine.

As more states allow telemedicine services to be covered under workers’ comp, the day will come that getting surgery abroad, especially in the Western Hemisphere countries, will become reality, and will go a long way to lower costs and speed workers back to work, and relieve the stress to the health care system that repeal of the ACA will have on health care in the US.

ERISA, Stop Loss and Unintended Consequences

“The problems of the world cannot possibly be solved by skeptics or cynics whose horizons are limited by the obvious realities. We need men who can dream of things that never were.”

John F. Kennedy

“Some men see things as they are and say why. I dream things that never were and say why not.”

Robert F. Kennedy

“It is not because things are difficult that we do not dare, it is because we do not dare that things are difficult.”

Seneca

Those quotes were included at the top of my June 19, 2013 post, “Clearing the Air: My Defense of Implementing Medical Tourism into Workers’ Compensation” where I defended myself against the charge that I was offering “simplistic solutions” to medical travel and workers’ comp. In that post, and in “The Faith of My Conviction: Integrating Medical Tourism into Workers’ Compensation is Possible and is not a Pipe Dream” I acknowledge that is won’t be easy, but there are ways to do it.

In my last post, “Self-Insured Employers Fail To Adopt Medical Travel“, I discussed the reasons given by Irving Stackpole for why US employers have failed to adopt medical travel into their corporate health plans.

In conversations with a noted ERISA and medical travel expert, I have been making the case that laws and regulations such as ERISA, Stop Loss, and other “barriers” erected decades ago, in order to address specific problems such as tort claims, aggregate claim losses, etc., have the unintended consequence of holding back the globalization of health care, which includes workers’ comp.

I have addressed the legal barriers in comp in my White Paper, and found that there were outdated federal and state laws and regulations, intended to protect consumers, actually increase costs and reduce convenience, restrict public providers from outsourcing certain expensive medical procedures, and that federal laws inhibit collaboration, while state licensing laws prevent certain medical tasks being performed by providers in other countries.

Let me state here that I, in no way, am advocating the removal of these laws and regulations. My chief argument is this: our best minds have split atoms, launched satellites and men into space, discovered cures for diseases plaguing humans for centuries, but to send patients to other countries for medical care is impossible, and not worth pursuing, smacks of cowardice or fear that it actually might save money and provide better care. Do we not have the best minds to figure out how to deal with these “barriers”, or are we too fearful and litiginous a society that we have given up accepting new ideas?

Every industry is being affected by two powerful forces today: globalization and automation. With globalization, jobs, plants and other forms of capital are moving across borders. With automation, jobs that were once held by humans and considered very dangerous, are being done by robots, and soon other jobs will be done by artificial intelligence.

Neither force can be stopped, and how we address the consequences of these forces is what many minds are working on right now. But to say that one industry is going to draw a line in the sand and say, “NO” and stop globalization from happening is either insanity or a deliberate attempt to profit from the maintenance of the status quo that many along the supply chain of medical care services, both within the general health care space and workers’ comp have carved out for themselves.

When I was in college, I studied International Relations, and back then, globalization was a word very few outside of academia ever heard. There was an organization created in 1973 by David Rockefeller and Zbigniew Brzezinski called the Trilateral Commission. Its purpose was to foster better cooperation between the countries in North America, Western Europe and Japan (the Trilateral countries) and their multinational corporations. In the ensuing decades, the Commission expanded the membership to the rest of the world, and globalization became a household word.

Coincidence? I think not, since the heads of major US, Western European, and Japanese companies were members, and so were many politicians, including a former peanut farmer from Georgia and most of his top administration personnel. Other politicians after him also have been members, from both sides of the political spectrum.

Their chief goal is to allow capital, goods and jobs to cross national borders, or to eliminate them altogether, and I doubt they expected the health care industry to stand in their way. These are men who generally get what they want, and damn the consequences. We see this in the breakup of the European Union, which many of them advocated for years, just like they advocated for NAFTA, CAFTA, the TPP, and other trade deals, and don’t give a fig about the impact they have.

So, it is important to realize that the only real thing preventing medical travel is what unintended consequences have on the growth and development of the industry. This is where the industry needs to focus its attention, not on slick advertising, but on hard work and cooperation to overcome these “barriers”.


I am willing to work with any broker, carrier, or employer interested in saving money on expensive surgeries, and to provide the best care for their injured workers or their client’s employees.

Ask me any questions you may have on how to save money on expensive surgeries under workers’ comp.

I am also looking for a partner who shares my vision of global health care for injured workers.

I am also willing to work with any health care provider, medical tourism facilitator or facility to help you take advantage of a market segment treating workers injured on the job. Workers’ compensation is going through dramatic changes, and may one day be folded into general health care. Injured workers needing surgery for compensable injuries will need to seek alternatives that provide quality medical care at lower cost to their employers. Caribbean and Latin America region preferred.

Call me for more information, next steps, or connection strategies at (561) 738-0458 or (561) 603-1685, cell. Email me at: richard_krasner@hotmail.com.

Will accept invitations to speak or attend conferences.

Connect with me on LinkedIn, check out my website, FutureComp Consulting, and follow my blog at: richardkrasner.wordpress.com.

Transforming Workers’ Comp Blog is now viewed all over the world in over 250 countries and political entities. I have published nearly 300 articles, many of them re-published in newsletters and other blogs.

Share this article, or leave a comment below.

Self-Insured Employers Fail To Adopt Medical Travel

When I began my writing, one of the ways I saw medical travel could be implemented into workers’ comp was through employers who self-insure.

There are not that many companies who do self-insure for several reasons, one of which is the administrative costs and extra hoops they would have to go through just to get approval from state regulators to be self-insured. This is something most small employers will not do. More on what I think about this later.

Today, Irving Stackpole, President of Stackpole & Associates (a LinkedIn connection of mine), wrote an article in the International Medical Tourism Journal (IMTJ) about why US employers have failed to adopt medical travel benefits.

For the sake of transparency and honesty, I have never met Irving, but have had discussions with him a few times on LinkedIn in some of the groups we have in common. I have met his co-host of his radio show, Elizabeth Ziemba, when we both attended the 5th Medical Tourism and Wellness Business Summit in Reynosa, Mexico in November 2014.

In his article, Irving mentions that while some small employers such as HSM (who I have written about in earlier posts), Hannaford Supermarkets, the Casino and Hotel of the Blue Lake Rancheria Tribe in Northern California, and IDMI Systems have added medical travel to their health plans, he does not know of any large employers who have.

When I attended the 5th World Medical Tourism & Global Healthcare Congress in 2012, large employers such as Disney Institute, American Express, and Google sent representatives to speak at the Congress. If they attended, then surely their companies must be involved in some degree with medical travel? What did they discuss? Certainly not the weather (Hurricane Sandy was right outside the hotel).

But I digress, yet again.

According to Irving, six percent of firms offering fully-insured plans reported that they intend to self-insure because of the ACA. So, he is correct in that not many companies are self-insured.

However, Irving also states that it is estimated that the average self-funded plan covers between 300-400 employees, and that 59% of them in the US self-fund as part of their health plan.

And he goes on to say that many small companies are looking to self-fund to reduce their share of the cost burden, but that because small employers are not able to assume the same risk levels, stop loss rates are rising. This pressure, he adds will serve as a limitation on the expansion of self-funded health insurance into the smaller market.

Irving concludes that there are four reason why large self-insured companies would add an additional medical travel benefit to their insurance plans:

  • Current implementation of the ACA has distracted or absorbed attention of insurance markets, including self-insured companies. Many companies are wrestling with far issues of how many employees will be included/excluded, potential penalties, and avoiding fines under the ACA;
  • Self-insured plans are exempt from many of the more costly and burdensome requirements of the ACA as long as they don’t make significant changes, therefore they are careful about keeping their plans unchanged;
  • Reinsurance, or stop loss coverage may be limited for plans offering a medical travel benefit, and;
  • There is no history of outcomes , evidence or actuarial models to support the case among employers for a disruptive change such as international medical travel. Reports suggesting cost savings and quality outcomes are not yet supported by evidence.

One other factor Irving suggests as to why many employers have avoided medical travel is because many find it necessary to contract with a third party administrator (TPA) to collect premiums, manage membership enrollment, claims adjudication and payment. These TPA’s are sometimes referred to as providing “Administrative Services Only” contracts or “ASO” contracts, where they provide typical third party administration services, but assume no risk for claims payment.

Because of these contracts, Irving says that while economic logic suggests that self-funded employers should be interested in high quality, lower cost destinations, it is necessary to convince both the benefits manager and the TPA/ASO  of the value of being a destination provider, and the low risk associated with accessing international medical travel.

Okay, now it’s my turn.

“Impossible is just a big word thrown around by small men who find it easier to live in the world they’ve been given than to explore the power they have to change it. Impossible is not a fact. It’s an opinion. Impossible is not a declaration. It’s a dare. Impossible is potential. Impossible is temporary. Impossible is nothing.”

Muhammad Ali

While everything Irving wrote about appears to be factually true at the moment, and I cannot dispute what he says, the fact that employers have been unwilling to pursue medical travel is more complicated than the reasons he gives above.

True, the ACA has many things in it that may or may not seriously impact health care and the health insurance industry, but what he does not mention is that many of the things holding employers back pre-date the enactment of the ACA, and are more concerned with keeping health care the purview of those along the supply chain who profit the most from the system we have created, and not concerned with providing people either under health insurance or workers’ comp, with the best medical care possible, at the lowest cost, no matter where it comes from.

TPA’s and ASO’s and ERISA, and many other mechanisms such as stop loss insurance, and risk avoidance, etc., are mere barriers to the implementation of medical travel into both health care and workers’ comp.

Using my oft-time quoted analogy of going to the Moon, imagine if the baby steps we took to get there such as the Mercury, Gemini and early Apollo programs were not baby steps to the Moon, but actually barriers set up so that we are thwarted every step of the way to getting there or to go even further, such as landing humans on Mars. Don’t you think there would be people just like Irving who would say that it cannot happen?

That is why I quoted the late Muhammad Ali. For a poor black kid from Louisville, he sure had a better understanding of what can be than most folks who did not grow up like he did.

But this does not let the medical travel industry off the hook. I said so in my post, “Ensuring Patient Safety: Making Sure Medical Tourism Puts Its Money Where Its Mouth Is“.

But it is not just the industry itself that needs to come clean. Foreign governments and their travel ministries, the medical travel facilities, the providers, and the facilitators must present hard evidence that better quality and lower cost is possible, and so that when some of the dire predictions of the impact of the ACA are fully realized, or the US health care system collapses of its own weight (see my post, “Colorado “Single Payer” in Health Care Industry’s Sights“), medical travel as an alternative will become more acceptable to US employers, large and small, and not just for health care, but for workers’ comp as well.


I am willing to work with any broker, carrier, or employer interested in saving money on expensive surgeries, and to provide the best care for their injured workers or their client’s employees.

Ask me any questions you may have on how to save money on expensive surgeries under workers’ comp.

I am also looking for a partner who shares my vision of global health care for injured workers.

I am also willing to work with any health care provider, medical tourism facilitator or facility to help you take advantage of a market segment treating workers injured on the job. Workers’ compensation is going through dramatic changes, and may one day be folded into general health care. Injured workers needing surgery for compensable injuries will need to seek alternatives that provide quality medical care at lower cost to their employers. Caribbean and Latin America region preferred.

Call me for more information, next steps, or connection strategies at (561) 738-0458 or (561) 603-1685, cell. Email me at: richard_krasner@hotmail.com.

Will accept invitations to speak or attend conferences.

Connect with me on LinkedIn, check out my website, FutureComp Consulting, and follow my blog at: richardkrasner.wordpress.com.

Transforming Workers’ Comp Blog is now viewed all over the world in over 250 countries and political entities. I have published nearly 300 articles, many of them re-published in newsletters and other blogs.

Share this article, or leave a comment below.

Courts Striking Down Work Comp Laws

Coming back around to the constitutionality of aspects of the various state workers’ comp laws, an article by David De Paolo last week, suggested that rather than corporate America dismantling workers’ comp, it is the courts who are actually doing so.

David says that state supreme courts will be the ones doing the dismantling this year, piece by piece.

A week and a half ago, I wrote that the Oklahoma WC statute relating to the permanent partial disability deferral provisions of the state’s workers compensation statutes of 2013, was struck down in a 7-2 decision.

This decision was first reported in The Oklahoman.

And David also reported in the same article, that the 1st District Court of Appeals in Florida said that the state’s statutory limits on the payment of attorneys for injured workers was unconstitutional.

So while ProPublica and others rightly or wrongly accuse corporate America, the Koch Brothers, ALEC, ARAWC, the Illuminati, Martians, and anyone else we left out, it is the men and women who wear black robes who are striking down the workers’ comp laws in their states.

Is this a coincidence? Is this a vast conspiracy of right-wing jurists and those who put them on the bench? That is hard to say because we don’t know these people at all, who appointed them, and what their individual political motives are.

But if these decisions are any indication, the courts are ruling more in favor of injured workers, than their employers.

If you read De Paolo’s article and the cases linked to them, as well as the OK case, you will see that the courts are generally siding with workers.

What does this mean?

Well, it is too early to tell, but if these trends continue this year, 2016 may be the year the injured worker gets a little break. But we still have laws, regs, and rules in place that are holding back workers from getting the best health care available, at lower cost, no matter where that happens to be, even if it is not within the borders of their state or the country.

And that is something courts in the future will have to decide.

Borderless Healthcare: A Model for the Future of Medical Care in Workers’ Comp

By now, many of you, my faithful, and not so faithful readers (and critics) have been aware of my strong interest and passion about implementing medical tourism into workers’ comp.

The critics have not silenced me, they have only made me more determined than ever to get the word out…MEDICAL CARE UNDER WORKERS’ COMP IN THE US WILL HAVE TO GLOBALIZE, OR ELSE IT WILL FAIL TO PROVIDE ADEQUATE CARE AT LOWER COST AND AT EQUAL OR BETTER QUALITY THAN WHAT IS RECEIVED CURRENTLY.

I capitalized the above because in the three plus years I have been writing this blog, it takes a bit of shouting to get heard in this world.

To make the point I just shouted, I participated yesterday in a webinar on Bloomberg BNA.com produced by Manatt, Phelps & Phillips, LLP/Manatt Jones Global Solutions.

For all of you political junkies out there, Charles Manatt was the Chairman of the Democratic Party from 1981 to 1985, in the first term of that has-been Hollywood actor the GOP shoved down our throats.

The webinar, “Healthcare without Borders: The Opportunities and Challenges of Medical Tourism”, was an almost ninety minute, four-part presentation given by two Managing Directors, a Partner, and a Medical Director of a Mexican hospital system.

The presenters were Jon Glaudemans, Managing Director of Manatt Health Solutions, Andrew Rudman, Managing Director of Manatt Jones Global Solutions, Linda Tiano, Partner with Manatt, Phelps & Phillips, LLP, and Dr. Alfonso Vargas Rodriguez, Medical Director of Hospitales H+.

While the focus of the middle of the presentation dealt with conducting medical tourism in Mexico, the information presented by Mr. Glaudermans was concerned about the trends in healthcare that are pointing to greater demand for medical tourism, and are elaborated in the following graphic:

Megatrends

Source:  2016+Medical+Tourism+Deck.pdf Manatt, Phelps & Phillips, LLP

Here are the key points from Mr. Glaudemans’ presentation slides:

  • Consumers pay more and make more care decision, using social
    media/apps to acquire price/network data.
  • Providers take risk for population/patient/product outcomes, requiring new care models and contracts
  • Care monitoring and delivery move out of traditional settings, shifting the locus of/focus on patient loyalty
  • Providers and payers consolidate to manage costs and enhance power, fighting for CM (care management) space
  • States become more active regulators and purchasers, creating marketplace mosaics and more “experiments”
  • Data on health status and effectiveness become widely available, changing practice and payment patterns
  • Bigger datasets yield insights, informing personalized care and challenging price-setting and patient privacy
  • Employers’ role continues to erode, while exchange plans sharpen focus on multi-year patient loyalty
  • Digital natives’ and baby boomers’ interests coalesce, forcing focus on new ‘late-life/end-of-life’ care models
  • Visibility into global pricing and care models improves, requiring providers to justify value and pricing
  • Social determinants accepted as major cost driver, leading to increased focus on service integration

Naturally, many of these megatrends will not pertain to workers’ comp, but given the fact that comp sometimes follows the lead of healthcare, it is not out of the realm of possibility that some of these trends will be felt in medical care for workers’ comp.

Andrew Rudman’s presentation focused on what medical tourism is, and why Mexico is an ideal medical tourism destination for Americans. The main thrust of his presentation is the proximity to the US, the flight times between major American cities and those Mexican medical tourism destinations he focused on in the discussion.

Mr. Rudman also provided a cost comparison chart between US and Mexican costs of certain medical procedures, which is shown below.

Cost comparison 2012

Source:  2016+Medical+Tourism+Deck.pdf Manatt, Phelps & Phillips, LLP/PROMEXICO

Dr. Rodriquez discussed how Mexican doctors become certified in their sub-specialties and how they get re-certified once they are certified by their respective boards. In addition, he showed slides about the various hospitals in the Hospitales H+ system, and for our purposes here, outlined the price differential for certain orthopedic surgeries at the various hospitals in their system versus that of the US.

Ortho surgery prices

Source:  2016+Medical+Tourism+Deck.pdf Manatt, Phelps & Phillips, LLP/Hospitales H+

Lastly, Linda Tiano covered the legal issues of medical tourism, and those of you who have been reading this blog for three years, know that my original paper covered some of these issues, and I raised them in my presentation in Reynosa, Mexico in November 2014.

Here are the key points Linda made regarding medical tourism benefits.

Medical Tourism Benefits

Source:  2016+Medical+Tourism+Deck.pdf Manatt, Phelps & Phillips, LLP

3rd Party Facilitator

Source:  2016+Medical+Tourism+Deck.pdf Manatt, Phelps & Phillips, LLP

Liability issues

Source:  2016+Medical+Tourism+Deck.pdf Manatt, Phelps & Phillips, LLP

HIPAA

Source:  2016+Medical+Tourism+Deck.pdf Manatt, Phelps & Phillips, LLP

State Regs

Source:  2016+Medical+Tourism+Deck.pdf Manatt, Phelps & Phillips, LLP

At the end, I asked the question, “do you see the possibility of implementing medical tourism into workers’ comp, and what are the legal issues with that?” Ms. Tiano mentioned the state-specific laws regarding workers’ comp, and said that the workers’ comp industry is way behind health care, to which I heartily agreed.

So you can see from this brief, but thorough review of the presentation, that medical tourism is a serious research area for many interested parties. Yet, you guys in work comp refuse to see, hear or speak about the truth of what is happening around you. So here is another picture for you.

hear-no-evil-see-no-evil-speak-no-evil

This is the workers’ comp industry on the subject of global health care and medical tourism…three deaf, dumb and blind monkeys clinging to the same old statutes, laws and regulations that haven’t changed since the days of Taft and Wilson.

So when are you going to catch up to the rest of the world, and to the globalization of health care? In the 23rd century? When are you going to admit to yourselves that automation, new technology, the Internet of Things, telemedicine, etc., are going to make you guys OBSOLETE… to borrow a term from “The Twilight Zone”.

I have a vision for the future of medical care in workers’ comp. What you have is the same old, same old, and expecting different results. That’s not only crazy, that is doing a disservice to the people workers’ comp is supposed to be for, the claimant.

But suit yourselves…the dinosaurs are waiting to greet you.

 

 

 

Satori Files For Bankruptcy: What that Means for Medical Travel

As reported last month by US Domestic Medical Travel.com, Satori World Medical, Inc., a company based in San Diego, filed for bankruptcy.

When news of this story broke, I inquired with my contact at US Domestic Medical Travel.com to learn what this meant for the patent Satori had taken out that had a chokehold on the growth and development of the medical travel sector, both domestic and international.

Her reply was that she was not sure, so I looked up what happens when a company goes bankrupt. Most of the information concerned companies who manufactured products and what happens to the patents to those products after a bankruptcy. The gist of what I found was that they transfer to the receivers/liquidators.

But since Satori’s patent is for an idea, and not a tangible asset like manufactured goods or inventory, I doubt the receivers/liquidators for this action would be willing to take this asset. What would they do with it?

So, instead of wondering, because that may be a fruitless exercise, let’s look at what the patent was all about, what it allowed and did not allow, and then you can decide how best to model your business plan going forward.

The Satori patent, trademarked as the “Health & Shared Wealth Program”, is actually two patents; the first, U.S. Patent 8160897, titled the “Satori Integrated Health & Financial Benefits System and Method” and U.S. Patent 8224668, a Continuation-in-Part to Patent No. 8162897.

They are part of a portfolio of other patents of intellectual property that regard the calculating and sharing of the dollar savings from a medical travel health benefit. The patents provided Satori with exclusive rights to the only permissible medical shared savings model in the medical travel industry.

I know what you all are thinking, how can anyone patent an idea such as this? Isn’t this restraint of trade, you may wonder?

Well, as I am not a patent attorney, nor an intellectual property expert either, I would think not, except that was the case before the bankruptcy.

As Satori’s own website states, the Health & Shared Wealth Program supports organizations by lowering their cost structure for health benefits by providing plan members with a highly-valued benefit option at no cost to the plan sponsor or members.

The parent patent, they continue, is a system and method that calculates the savings generated when a patient selects medical care outside the US.

It waves all co-pays, deductibles, and/or co-insurance, making the selection of outbound medical care a 100% medical benefit for the patient. In addition, it shares the savings between the patient and the insurer/employer.

I want to stop here in the explanation of the patent to tell you my idea, and why this patent seems to me to be a restraint of trade issue and a virtual monopoly.

My idea was to implement medical travel into workers’ compensation in the US, and along the way, after writing my paper on the subject, and this blog, I learned from other individuals that the best way to do so was to offer an financial incentive from the savings to the claimant/patient from either his employer or insurance carrier.

At the same time, I learned from one individual, that in order for this to be advantageous, the savings had to be greater than $5,000 for medical care received outside the US. So for example, if a knee surgery in the US cost $30,000, in order to convince an employer or insurance company of the efficacy of outbound medical travel, the cost of that knee surgery would have to be $25,000 or less.

How much the claimant/patient would receive and when and how they would receive it is a matter of discussion. It could be a percentage of the savings, a flat-rate of say, $2,000 or $2,500, or come from the overall settlement of the claim, but that could take years to realize.

Returning to the patent, the Health & Shared Wealth Program, Satori states, precludes certain entities such as medical travel/medical tourism facilitators (I bet you are hoping mad at this point; I sympathize), health plans, self-funded and fully insured employers, Taft-Hartley trusts (labor unions), unions, workers’ compensation carriers (this got me mad), municipalities, pension plans, etc., from offering any shared savings model similar to the one described above to their clients and/or plan members without written permission from Satori (now you must be steaming!!!!).

So, what does this mean? If Satori is out of business, we can all take a sigh of relief that now the wicked witch of the west (Satori) is dead. What comes next is up to you. Prior to the announcement, there were ways to get around the patent’s restriction. Now, that may not be necessary.

My suggestion is get yourselves some good IP attorneys to see if you are good to go, and if you are given the green light, adjust your business model and plan accordingly. You will only benefit from the fall of the house of Satori.

 

SPOTLIGHT Interview – October 31, 2013

This is the original interview published on October 31, 2013 by Medical Travel Today.com.

Medical Travel Today (MTT): Tell us your position in the medical tourism industry, as well as your thoughts on integrating medical tourism into workers’ compensation cases in the U.S.

Richard Krasner (RK): Currently, I am a blogger, blogging about the implementation of medical tourism into workers’ compensation.

I first began looking into integrating medical tourism into workers’ compensation when I needed a topic for a paper in my Health Law class as part of my M.H.A. degree program in March of 2011. A lawyer who was working for a medical tourism facilitator company at that time, and who had written an article in a law journal about medical tourism, gave me the idea after my first topic did not pan out. She thought that the legal barriers to implementing international medical providers into workers’ compensation through medical provider networks was a good idea, and since I had a small interest in the subject of medical tourism, I submitted that as my topic to the instructor.

He gave me his approval and, as I started to do my research, I found many articles on medical tourism and nothing on medical tourism and workers’ compensation, so I knew my task was a difficult one. But as the point of the paper was to write about a legal issue and persuade people one way or the other, I felt that I could mention the lack of literature on the subject and perhaps open up dialogue in that area. I then found a roundtable discussion from the January/February 2008 issue of the journal Telemedicine and e-health.

In the discussion, I found something that I had been looking for, but had not expected in a medical journal: a validation from four of the participants for my idea to implement medical tourism into workers’ compensation. I made their discussion the centerpiece of my paper, and thus my argument in favor of implementation. They said essentially that they thought that medical tourism could work for non-emergent, i.e., non-emergencies or long-range issues, such as knee or hip replacement, chronic back injury and repetitive action injuries, and that it would not be a leading offering. That is when the light bulb went on, and I realized that it could be accomplished as an option for the injured worker to consider.

Initially, my research consisted of finding articles that discussed medical tourism in destinations, such as India, Singapore and Thailand, and my thought then was that it might be a stretch to send injured workers that far away, but that maybe it could be done. Later on, as I got more involved in medical tourism through my attendance at the 5th World Medical Tourism and Global Healthcare Congress in October 2012, and through conversations online with another lawyer, I realized that the best chance for this to happen was in Latin America and the Caribbean, and that given the rise of the Latino population in the U.S., sending patients home to their home countries for treatment would present no language or cultural barriers, and would allow friends and family in those countries to visit them during recovery, which will improve their self-esteem and improve their recovery time.

I have since come to believe that all injured workers could be offered this as an option, not just those of Latin or Caribbean origin.

MTT: How will the integration benefit individuals, health insurance companies, and the entire medical community, both domestically and internationally?

RK: I believe first and foremost that medical tourism will have its most important benefit on the individual because of some of the things I mentioned above, namely little or no cultural or language barriers to overcome between Spanish or English in most cases, or between Portuguese or other languages in the region. Also, as I said, their friends and families back home can visit, which would make their recovery more relaxing, more pleasant and would show them that the patient is not sitting at home just collecting a check. It would also give the patient greater self-esteem and speed recovery. Finally, by being treated in the better hospitals in the home country, a patient’s friends and family will see that their loved one is being cared for by the best doctors and at the best facility in their country.

I think the benefit for the health insurance company or, in this case, the workers’ compensation carrier would be that they will not have to pay for expensive procedures, such as hip or knee repair/replacement, shoulder surgery, spinal fusion surgery or carpal tunnel surgery. This is despite the fact that many states have fee schedules for workers’ compensation, which tells providers how much to charge the carrier for each procedure, and which may be less than the normal fees charged. Nonetheless, as the recent New York Times article indicates, the U.S. has the highest cost for healthcare, and it is not slowing down, nor has the average medical cost for lost-time workers’ compensation claims, as I have written about in my white paper and my blog.

I think for the entire medical community domestically and internationally, it will have several benefits, the first of which will be the realization that healthcare is globalizing and that it is no longer possible to consider that quality medical care is available only in the developed world. Second, it will lead to the development of international accreditation standards, quality standards and other standards that up to now have hampered medical tourism’s expansion and growth.

These standards will take time to be adopted and will be expensive to implement for the medical tourism facilities involved, as it has already been for the implementation of other standards and forms of accreditation, such as from the Joint Commission International.

Thirdly, it will have the benefit of bringing American patients to medical providers in other countries, those who otherwise would never be seen by foreign doctors except for those who have gone to foreign-born doctors practicing here in the U.S., whether in private practice or in a hospital setting. Fourth, and this is more of an issue with workers’ compensation cases, doctors abroad will be able to get broad experience treating work-related injuries that they have never seen, thus adding to their medical experience, and providing their fellow citizens with that experience should they ever require it.

Medical tourism will open up global healthcare to all inhabitants of this planet, not just those looking for cosmetic surgery, or procedures that are too expensive or unavailable in their home countries. It will certainly open it up to those who otherwise could not afford to travel out of their country for treatment.

MTT: What would you say are the steps necessary to take in order for medical tourism to be integrated into workers’ compensation effectively?

RK: First, there has to be a removal of all or many of the legal barriers that I mentioned in my white paper, as well as many others that I could not or did not mention. Also, there has to be some understanding on how the legal issues surrounding medical tourism can be solved such as malpractice, legal liability, privacy issues, medical records transfers, etc.

There are financial steps that need to be addressed, such as which currency the payments will be made in, any incentives to injured workers, referring physicians, treating physicians, destination hospitals, as well as travel insurance coverage for things not covered under workers’ compensation. And lastly there has to be a willingness on the part of employers and insurance companies, third party administrators, and lawyers to accept medical tourism as part of workers’ compensation. I have discussed this with several people recently through emails, and in the past six months since beginning my blog, and have written about this as well.

As the Chinese say, a journey of a thousand miles begins with the first step. An industry like the workers’ compensation industry in the U.S., which is concerned with issues, such as pain medication abuse, physician dispensing of drugs and dealing with cost-curbing strategies that have failed, must come to the realization that the journey for them must begin now — before costs skyrocket any further.

MTT: What can you see being potential deterrents in integrating medical travel benefits into workers compensation?

RK: First of all, let me say that I don’t have all the answers, and I cannot foresee all contingencies and problems associated with traveling abroad for care. But I do want to make this clear so that your readers will not think that I don’t know what I am talking about, or that they will think that integrating medical tourism into workers’ compensation will be easy and not fraught with difficulties and complications.

It will not be easy, there are and will be complications from flying after undergoing surgery abroad, just as there are if the patient was treated at the local hospital. I am not a medical person, so my knowledge of how patients will tolerate air travel after surgery or what complications will arise is beyond my experience. But I can say this: I don’t see a difference between a patient who traveled abroad for medical care as a private patient for cosmetic, body improvement or other forms of surgery usually associated with medical tourism and a patient who is traveling abroad for surgery as a result of an on-the-job injury. Yes, there are differences in the process of treatment and aftercare and recovery, but if the private patient can develop complications, so too can the workers’ compensation patient.

To answer the question then, I think deterrents include a lack of will, fear of lawsuits in countries with laws that do not favor the insurance company or the employer, malpractice insurance and legal liability that does not meet American standards, employee choice to stay at home, and pressure from special interest groups like doctors, hospitals, pain clinics, rehab facilities, trial lawyers, etc.

MTT: During a time of rapid healthcare reform, why do you think medical tourism hasn’t been connected to workers compensation already?

RK: Because there is so much uncertainty over the impact the Affordable Care Act will have, not only on healthcare, but also on workers’ compensation. In my research on that subject, I found that there will be little immediate impact, but down the line there will be, especially as more people get health insurance, and also because of the doctor and nurse shortage, which will affect both healthcare and workers’ compensation.

There are critics of the law who say it will raise costs, and then there are those who say it will lower costs, as some have already pointed out recently. But only time will tell who is right and who is wrong. Finally, I don’t think many in the workers’ compensation industry have ever considered looking abroad, except to plan their next vacation.

MTT: Is there anything else you would like to add at this point that you think is significant in terms of medical tourism, workers’ compensations and/or the integration of the two?

RK: Yes, as I said in my blog post, The Faith of My Conviction, what is needed is the will to do it, the courage to make it happen, the hard work to get it there, and the determination to bring the two industries together. I have had experts tell me that it won’t happen, but I pointed out right away in my post the discussion I found between the four medical professionals, and I believe that as medical professionals they have a better understanding of the issues involved than I do as a layman. I trust their judgment of the issue and defer to them for my belief that it can be done.

So who is right and who is wrong? I don’t know the answer to that, but I do know this: for 20 years, the average medical cost for lost-time claims has gone from around $8,100 to almost $30,000 with no decrease in cost, but with a slowdown in the rate of increase. Is that progress? Is that a sign that all other avenues tried have not succeeded? Perhaps it will take higher costs to wake people up to the reality that medical care, like all other goods and services, always goes to those places where the goods or services can be produced at cheaper cost with better quality.