Category Archives: Undocumented

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.

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The Fiefdoms of Fools

Fiefdom: 2. Informal. anything, as an organization or real estate, owned or controlled by one dominant person or group.

Source: Dictionary.com

Last July, I wrote two pieces, The Stench of Fraud: Why Workers’ Comp Can No Longer Be a Closed System and The Stench of Fraud, Continued. These articles dealt with the issue of fraud in the workers’ compensation system. The first article was based upon David De Paolo’s article about physicians or hospitals in CA using phony or unapproved implants on patients.

The second article discussed the plight of a woman, also in CA, who I called “Ms. X”. Ms. X was injured in the course of her employment, and subsequent to her injury, was injured several times by the treating physician, the medical staff at facilities where she received treatment, her former plaintiff attorneys, the defense attorneys, the insurance company, and finally her employer, who fired her.

I let Ms. X speak in her own words so that the reader would understand the pain and suffering she was feeling was real, and not something that I made up to bolster my argument for transforming workers’ compensation. There are hundreds, if not thousands of Ms. X’s and Mr. X’s out there who are subjected to the dark side of the workers’ comp system in the US. And there are many others who file claims who never suffer abuse or fraud at the hands of the system.

But yet, there are still more vile and disgusting things happening to workers in this country, injured or not, legal or undocumented, native born or foreign, as David De Paolo discussed back in July in his article, How Dare They. David’s website, WorkCompCentral.com reported that over one hundred undocumented workers at a fruit packing plant in South Florida were arrested for workers’ compensation fraud, although only a few of them actually filed claims for workers’ compensation benefits. The company they worked for, Fruit Dynamics, hired the workers who were from Guatemala, Mexico, Honduras and El Salvador, knowing that they were undocumented.

The owners were never suspected in any complicity in the fraud, according to Maj. Geoffrey Branch of the Florida Division of Insurance Fraud. “At this time, we do not believe anybody affiliated with the ownership or management had any idea that any of these documents were fraudulent,” Branch said,“We believe that they thought they were on their face value valid, authentic documents.”  As David points out, the reason for the raid in the first place was because the original complaint was against the employer for intentionally hiring undocumented workers in a pattern of behavior and practice to underreport payroll and intimidate workers out of benefits for work injuries.

David also said that an attorney who had represented several of the workers over the years made the complaint to the Division because there was a pattern of practice that he noted.  The attorney said that the employer’s hiring and management practices were intentionally done to minimize workers’ compensation liabilities and abuse immigrant workers. The employer faced no retribution whatsoever from the law even though there is documented evidence that the company knew what it was doing and its insurance carrier went along with the plan in complicity, David added.

In today’s article, David revisits the case in Florida from July, and reports that the undocumented workers were given “diversion“, which would allow the charges to be dropped assuming compliance by the accused. However, the employer is under investigation, according to a report by WorkCompCentral.com. At the time of the arrests, the Chief Financial Officer of Florida said that the lead the investigators were following would “result in dozens of workers’ compensation arrests and many arrests for identity theft that have been potentially devastating for victims.”

Yet, as David pointed out in his article, that was not the case. The fact is that the few workers’ compensation cases that were in process by workers injured at the Fruit Dynamics plant in Naples, FL resulted in termination of the workers – the employer clearly was sending a message to its undocumented workers: don’t file a claim for injury. Clearly, David continues, the employer threatened, and executed, retaliatory action in order to keep its undocumented workforce complicit, and quiet.

Back in July, David stated that the arrests were “lightly veiled discrimination based on race. The masters aren’t prosecuted for their fraud and deceit, but the powerless workers are punished for their enslavement.”  On top of the fact that Fruit Dynamics engaged in immigration fraud, it is also under investigation for payroll fraud. David concluded that this is a case of racial discrimination bordering on enslavement.

Which brings us to the title of this article, The Fiefdoms of Fools. By that I mean that within the workers’ compensation system in the US, there are various fiefdoms that have been carved out and control the different spheres of influence each of them represent. As David discussed in his article about fraud in July, there are the fiefdoms of physicians and hospitals who commit fraud against the insurance companies and patients.

There are, as I discussed in my second article on the subject, fiefdoms of attorneys, both plaintiff and defense who abuse the system and the claimants, there are insurance companies who commit fraud against the employers, there are fiefdoms of medical facilities who commit fraud by falsifying medical records, there are fiefdoms of physicians who abuse and maim and injure the already injured for their own greed, and then there are the fiefdoms of employers, like Ms. X’s and Fruit Dynamics who terminate employees for filing a claim when they were legitimately injured, or in the case of Fruit Dynamics, unjustly terminated to cover up criminal activity of the company.

But we don’t have to look at what is going on in, or around the workers’ compensation system to see where there are other fiefdoms of employers who are abusing, intimidating, threatening, or retaliating against their employees. You only have to pick up a newspaper every now and then and read about a company like Wal-Mart eliminating health insurance for its employees, or the company that fired a worker who complained to his cable company Comcast, after Comcast contacted the employer.

It does not take much to learn that the American worker is being subjected to vile, disgusting, discriminating and obscene acts by their employer as a means to control and dominate them, in much the same way feudal serfs were controlled and dominated by their feudal masters hundreds of years ago. Each feudal lord had his own fiefdom that he ran as he saw fit. It is no different today with American employers and their employees. We have a former union president and his party to thank for that. The union movement has made many mistakes, but the Republican Party’s war on workers, in and out of unions is one reason why these fiefdoms exist.

Beyond the employee/employer dynamic, there are other kinds of fiefdoms that pertain to the subject of this blog. These fiefdoms are controlled by the various entities in workers’ compensation that have a stranglehold on the very way workers’ compensation claims are adjudicated, processed, treated and disposed of. The workers’ compensation third party administrator firms, claims management firms, pharmacy benefit management firms, bill review firms, and other service providers all have carved out their own little fiefdoms that they control and manipulate for their benefit and profit.

I began this article by defining the word “fiefdom”, but as the title implies, there can be more than one fiefdom, which is why it is plural in the title. As for the part about fools, what would you call people who insist on doing the same thing over and over again, expecting different results; what would you call employers, carriers, physicians, hospitals, medical facilities, lawyers, service providers and the rest who prey upon, abuse, harass, intimidate, retaliate, threaten and terminate employees for no other reason than filing a claim for benefits they rightly deserve after being injured on the job; and what would you call people who knowingly commit fraud for profit? I’d call them fools.

NAFTA, Work Comp and Cross-Border Medical Care: A Legal View

Here is a blog post from David DePaolo that has a bearing on cross-border medical tourism between the US and Mexico, and how workers’ compensation is impacted by the North American Free Trade Agreement (NAFTA).

http://daviddepaolo.blogspot.com/2014/01/the-conflict-between-nafta-and-comp.html?utm_source=feedburner&utm_medium=feed&utm_campaign=Feed%3A+blogspot%2FbJOWY+%28DePaolo%27s+Work+Comp+World%29

The legal case cited by David is the reverse of one of the cases I cited in my White Paper, Legal Barriers to Implementing International Medical Providers into Medical Provider Networks for Workers’ Compensation. It also follows up with my earlier post, Do “Free Trade” Agreements Help or Hinder Medical Tourism and its Implementation into Workers’ Compensation?

And on the heels of my post, Cross-border Workers’ Compensation A Reality In California, it would seem that rather than being an hinderance to medical tourism across the US border, NAFTA is opening it up in both directions.

Would that other trade agreements allow for more medical tourism into the rest of Latin America and the Caribbean, and that state work comp laws, rules and regulations be amended to open the system to lower cost, higher quality medical care abroad that medical tourism can provide.

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Immigration and Workers’ Compensation: Round Two

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Now that the summer is almost over, and we have had a brief, educational interlude, thanks to my recent quiz and the article about the 1798 mandated health care law for merchant sailors, let’s turn back to more serious and more immediate subjects that are relevant to our times.

One such subject is immigration, and thanks to both Joe Paduda and Peter Rousmaniere, today’s post will build upon that subject, as I have previously written about it in my earlier 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, as well as my post, Survey says most immigrant workers unaware of Workers’ Compensation: What this means to Workers’ Compensation and Medical Tourism.

Joe’s post today, Immigrants in the workforce – and implications thereof, mentions that one of every seven workers in the US is foreign-born, and that about half are Hispanic and a quarter Asian.  About a third of the foreign born workers are undocumented.

Peter’s post, Foreign Born Workers Take Center Stage, in WorkCompWire.com, reiterates some of the statistics I mentioned in my posts on the subject, that foreign workers are skewed toward above average injury risk jobs, and sustain a large share of the nation’s annual three million work injuries.

He goes on to add that in 2012, there were 25 million foreign-born persons in the U.S. labor force, comprising 16% of the total workforce. Hispanics accounted for 48% of the foreign-born labor force in 2012, and Asians accounted for 24%. (Recently Asians have been entering the U.S. at higher levels than Hispanics.) Undocumented workers account overall for about 5% of the nation’s total workforce and roughly one third of foreign-born workers.

There are three key takeaways for those in the workers’ compensation arena to be aware of:

      • A foreign born worker poses higher injury risk due to language barriers, cultural miscues and poor health literacy.
      • The growing presence of immigrant workers is not temporary and reversible. It is part of global economic forces. Some 150 million workers globally are estimated to be working outside their country of origin.
      • Private sector employment growth has been and will continue be in fields with relatively high immigrant participation, ranging from software engineers to personal health aides.

Peter also details which industries are more likely to have high percentages of foreign-born workers and what that entails for future workers’ compensation injuries, something I also mentioned in an earlier piece. A key passage in his article states the following:

When you estimate the number of future work injuries, taking into account the injury rates of the individual jobs and their expected growth of openings, you find that immigrant workers will likely sustain 20% — one of every five – of work injuries.

The implications of this are clear as Joe points, out in his blog post today, and that I have already touched upon in the Survey piece, namely that:

Given these facts, it might be worth the workers’ compensation industry’s while to explore and seriously consider medical tourism as an alternative, but as much of the industry is focused on the issues of opioid abuse and the physician dispensing of drugs, which are certainly important issues, they nevertheless cannot blind the industry to other issues such as the impact of immigration on workers’ compensation, and to the alternatives that are out there to deal with them.

As I have been saying for some time, the implementation of medical tourism into the American workers’ compensation system is not just some fanciful dream or exercise in seeing myself in print. It is a rational, thoughtful and reasoned alternative to the high cost of medical care, not only within the general health care system of the US, but within the niche market that is the US Workers’ Compensation system.

As Joe and Peter so skillfully point out, and as I have done so in the past, the future American workforce will be made up of men and women who either were born in, or whose families came from countries in the Latin American and Caribbean region.

Sending injured workers to these and other countries in the region for medical treatment is a logical idea because of language and cultural barriers, access to quality medical care in the best facilities in their native countries or similar countries, and the ability of friends and relatives living there to visit the injured worker while recuperating from surgery, and therefore making recovery faster and more likely to have better outcomes.

If Peter’s 20% figure is correct, then it is safe to assume that a percentage of those injuries will require surgery at some point in the treatment process.

And if they will require surgery, what guarantees do we have that negotiations and fee schedules will bring down the cost of these future surgeries here at home, when a cheaper, better quality alternative is just a short flight away from the US mainland?

I have tried to get data on costs of certain surgeries common to workers’ compensation from a facility in the Caribbean and from hospitals in Latin America, and while I have also written about how difficult it is in getting such information, it nevertheless is imperative that the workers’ compensation industry gets behind this idea, and pushes for transparency from these facilities so that comparisons can be made between costs here and costs there, as well as quality.

But let me be clear, this is not going to be easy, and I have said it before, and it needs to be said again and again, it will be difficult to implement medical tourism into workers’ compensation, but can you really afford not to?

Recently, I had a conversation with the President and CEO of a surgery benefit management company, who also had the same idea, and in our conversation, he told me that he believed that the savings would have to be greater than $5,000, including surgery and airfare, for medical tourism to be a financially viable alternative to the high cost of surgery. His business model relied on getting the lowest cost domestically for his clients, which is still higher than what might be possible in Latin America or the Caribbean, but without reliable data, it is impossible to prove that claim.

What needs to happen is this, both the medical tourism industry and the workers’ compensation industry need to find each other and begin the process of determining how best they can help each other, and how best they can serve each other’s needs. One way for this to happen is for large, workers’ compensation services companies that already provide various services to the workers’ compensation industry such as medical care, translation services, and transportation services, through an in-house or contracted travel agency, so that their insurance carrier or employer clients can confidently and effectively secure better quality and lower cost care for their foreign and native born workforce in the event of serious work-related injuries.

The workers’ compensation industry needs to get focused on this issue, and the medical tourism industry needs to come clean with just how much it costs to perform surgery X, Y, or Z, and in which countries. Not being transparent and basing costs on multiple factors is like buying a car and being told that the price depends on the color, the time of day it is bought, the time of year, whether or not the salesman woke up on the right side of the bed that morning, and so on.

We cannot shut out the rest of the world, despite what the Tea Party wants, because like their Know-Nothing and Whig Party forefathers, they too will disappear from history if they continue to ignore the immigration issue. Let’s hope the medical tourism and workers’ compensation industries don’t either.

Survey says most immigrant workers unaware of Workers’ Compensation: What this means to Workers’ Compensation and Medical Tourism

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Introduction
Back in January, you may recall that I wrote a post about immigration reform and had invited a guest blogger to write about immigration as well. Also that month, I wrote about the hospitals located in Latin America and the Caribbean that I saw at the Medical Tourism Association Congress last October.

My purpose in writing those two posts was to tell people in the workers’ compensation and medical tourism industries that immigration reform was going to happen, that it could have an important impact on both industries, and that as far as the workers’ compensation industry was concerned, it would be a wise thing for them to consider medical tourism, especially to the “rising stars” of medical tourism in Latin America and the Caribbean, as the number of Latinos in the US is growing and more and more workers are of Hispanic descent, and because of immigration reform, more of them will become legal citizens able to come and go from the US to their countries of origin without fear of not being able to return or being deported once they did return.

Immigrant Survey Report
Now comes a report from New Hampshire, courtesy of David De Paolo’s blog, De Paolo’s Work Comp World, which says that a majority of immigrants to the US do not know that if they are injured on the job, they can get their medical care paid for by workers’ compensation. According to De Paolo, the New Hampshire Department of Health and Human Services (DHHS) reported that a recent survey of immigrants showed that most of them never heard of workers’ compensation.

The participants in the survey were asked if someone in the US ever told them that their medical bills would be paid for by workers’ compensation insurance, if they suffered an injury on the job. If they said yes, they were told to write down who had told them about workers’ compensation.

The report, Occupational Health Surveillance Immigrant Survey Report, conducted in February, indicated that 227 participants out of 366, or 62%, were not aware of workers’ compensation. Only 76 individuals, the report states, out of 126 who said yes to understanding workers’ compensation wrote down who told them about it. This included supervisors, human resources personnel, family members, friends, doctors, co-workers, teachers and the New Hampshire Coalition of Occupational Safety and Health (COSH) through classes on safety.

Twenty-nine of the 366 participants said they had been injured at work, with injuries to common body parts such as hands, fingers, wrists, backs, knees, feet, elbows, and abdomen. The majority of these injured had been in the US for either 4-6 years, or more than 6 years. 17 of the 29, who said they were injured on the job, had lost time claims.

23 participants had told their supervisors about their injuries, 4 did not report because they left the job due to the injuries, a cut finger was not considered “serious”, one felt that if the injury was reported, “nothing would change”, and one said they would be fired.

Report Statistics
The report includes several tables and graphs detailing respondents work experience in the US, population change in New Hampshire from 1990 to 2010 by ethnicity, demographics, continent of origin, race and ethnicity, education, jobs they held in the US and other employment data, as well as knowledge of workers’ compensation, number of weeks out of work, who paid the bills, treatment of injuries, working conditions and safety at work, supervisor support, and if they experienced bad treatment.

182 or 50% of respondents said they now worked for pay in the US, whereas 135 or 37% said they never worked for pay in the US before their present employment. The population change in NH from 1990 to 2010 saw a decrease in the White population from under 100,000 in 1990 to 40,000 in 2010, while the Black, Hispanic, Asian population increased, but not as much as the White population decreased. There was a decrease however in the Other category from 1990 to 2010. The largest group increase was among the Hispanic population.

The demographics showed that of the 366 immigrants, 41% were men and 58% were women (1% did not answer). The majority of respondents were between the ages of 21 to 60, with the 21 to 30 group representing 21%, the 31 to 40 group representing 24%, the 41 to 50 group representing 21%, and the 51 to 60 group representing 17%. The Under 21 group was 3% and the 60-plus group was 12%, with 1% leaving age blank.

Most of the respondents indicated that their continent of origin was Asia (44%), followed by the Dominican Republic/Haiti/Cuba at 14%, South America at 11%, Central America at 10%, Africa at 11%, Europe and the Middle East at 4% each, and 1% blank. If you add the Dominican Republic/Haiti/Cuba, South and Central America, you get 35%, indicating that the second largest region of origin is Latin America and the Caribbean, something medical tourism facilitators for that region should be aware of.

What does this mean for the Workers’ Compensation and Medical Tourism Industries?
It should be fairly obvious that for the workers’ compensation industry, this report means that they have not done a good job of keeping up with the changing face of the American workforce, and have ignored the immigrant worker for far too long, so that many of them do not know that when they are injured on the job, they can get their medical bills paid for, and can be compensated for lost time from work, which would help them get them back on their feet and keep their families secure.

It also means that labor unions and advocates for immigrants and workers have not done as good a job as they should have in getting the legal, and even the illegal immigrants the proper legal remedies they are entitled to under our laws. Perhaps it is fear that if the immigrants know about workers’ compensation, they will file more claims and thus raise their employer’s claims frequency, resulting in higher costs and premiums. Or perhaps they are afraid if they tell immigrants about workers’ compensation insurance, that somehow they will be deported for having made a claim. Whatever the reason is, it is quite obvious that there is a breakdown in communication between employer and employee, between unions and workers, between advocates for immigrant rights and the legal system and those they are dedicated to serve.

Some of the things that can be done are as follows:

  • When I did my internship for my MHA degree, the company I worked for had me check their database to update workers’ compensation rules and regulations regarding wall cards or panel cards that are required to be placed in an area of the employer’s workplace where workers can see it that will tell them what to do in case of an injury and how and where to file a claim, as well as to list any doctors chosen by the employer or insurer, or the state work comp agency that the claimant must use. It should be mandatory for all states to post wall cards, even if that state does not require a panel of physicians to be posted.
  • The wall cards should be written in several different languages, depending on the predominant ethnic and language groups in the particular state.
  • Allow advocates of the poor and immigrants, such as churches, unions, and advocacy groups to file claims for those injured immigrant workers who are too afraid to report claims to their bosses, or don’t know how to file, or who to trust. This should be in conjunction with legal personnel versed in the state’s workers’ compensation laws.

As for the medical tourism industry, this is an opportunity for the industry to step out of the shadows and open up to an underserved market of recent immigrants to the US from many of the same regions of the world in which the medical tourism industry is already sending Americans overseas for less costly and better quality healthcare. It is also an opportunity for the medical tourism industry to move away from being solely a province of affluent or middle class patients, and help serve those at the bottom of the social scale to get the same quality care the affluent and middle class are getting in medical tourism.

I have written some on the region more than a third of the respondents said they came from, Latin America and the Caribbean. With the majority in the survey saying they are from Asia that would mean that medical tourism could be implemented in workers ’ compensation by facilitators and destinations already providing medical care services in Asia, Latin America and the Caribbean. So it would not mean that they would have to do anything different than what they are already doing, just doing so for a different patient population.

It would require training and educating all levels of medical tourism to understand the difference in treating patients who are coming for care because they cannot get or afford such care back home, from those who get injured on the job and need care coordination, utilization management and review, and aftercare. But most important, it would require a change in direction for those facilitators and medical tourism destinations that only serve the well-to-do or middle class client.

Conclusion
It is apparent from the New Hampshire report that there is a serious problem in this country with regard to the awareness and knowledge of the laws and rights workers have when they are injured on the job. It was more than 100 years since the Triangle Shirtwaist Factory fire that took the lives of over 100 young women and girls, many of them Italian and Jewish immigrants, not unlike the immigrants of today.

Every state in the union eventually passed workers’ compensation laws as a result of that tragic fire, and workers won other rights such as unemployment insurance, the right to join the union of their choice as my grandparents did, the right to strike and collective bargain, and the right to have a decent retirement paid for by money they and their employers put into pensions and social security funds. All that is being, or has been lost or eroded over the past forty years, and there are people today in this country who would like nothing more than to eliminate all the gains workers have made in the last one hundred years.

The survey indicates just how fragile these gains are, because if future workers don’t know they have these rights; then it is much easier for the opponents of these reforms to get rid of them altogether and claim they never existed. The threat this survey poses to workers, employers and the workers’ compensation industry is not as great as the opportunity it affords for better workers, better productivity and less time lost from accidents on the job, and even lower claims costs if medical tourism is added to the mix.

The threat to the medical tourism industry from this survey is minimal, since right now it mainly deals with patients who can afford to go abroad or whose insurance companies will allow them to do so. The opportunity it represents is enormous, so it is in the best interest of all parties that the medical tourism and workers’ compensation industries work together, so that all patients can get the best and most cost-efficient healthcare available.