Tag Archives: Globalization

Medical Travel for Americans is Alive and Well

Many of you have probably thought that going abroad for medical care after passage of ACA was a thing of the past, or that the idea that workers injured on the job would go abroad was a “stupid, ridiculous idea and a non-starter”, have forgotten that medical care in the US is the most expensive in the world.

But the simple, undeniable fact is that we spend too much on medical care and get very poor results and outcomes, while other countries spend far less and get better outcomes.

Why are we so stubborn? And why hasn’t the workers’ comp world realized that they are fighting an uphill battle to lower costs every time they come out with some new strategy or cost containment measure that never lives up to its promise industry-wide?

Sure, there are individual cases where these companies save money for a particular client, but overall, the cost of medical care for workers’ comp still rises, even if that rise is slow at times, or appears to have shrunk, only to rise once again the next year, as seen in the NCCI State of the Line reports.

An article yesterday in Salon.com said that traveling abroad for medical care simply makes more sense — even regular teeth cleaning is four times more expensive in the US than it is in Mexico.

One of the first procedures mentioned in the article involves a Minnesota couple who went out of the country for an in-vitro fertilization (IVF) procedure. On her fourth trip to the Czech Republic, it finally worked, and she got pregnant. The procedure in the US would have cost them between $12,000 and $15,000.

While IVF is not something that workers’ comp would cover, the fact remains that procedures cost far too much in the US, and in the case of IVF, only have a 29% success rate, according to a CNBC report cited in the article.

An estimated 1.7 million Americans traveled abroad for care in 2017, according the Josef Woodman, CEO of Patients Beyond Borders, and author of the same titled book. In my seven years of studying medical travel, Josef Woodman’s name has figured prominently in many articles and forums of discussion on the subject.

The article goes on to say that that is 10 times more than the 2008 estimate from Time magazine.

Some of the top destinations for medical care are: India, Israel (always go to a Jewish doctor first), Malaysia, Thailand, Taiwan, South Korea (unless that little twerp up north gets an itchy trigger finger), and Turkey.

However, there are other, more accessible destinations closer to home like Mexico, Costa Rica, Panama, etc.

Typical operations are orthopedic or spine surgery (are you listening work comp world?), reproductive operations, cardiovascular and eye surgery.

For example, a coronary artery bypass graft (CABG) in the US costs an estimated $92,000 (you could buy a couple of nice cars for that amount), whereas in India, the same operation would cost $9,800.

A total knee replacement (are you still listening ,workers’ compsters?) cost around $31,000 in the good ole US of A, but in Thailand, costs around $13,000. Tell me how you can save that much on a knee replacement using any of your so-called cost saving schemes?

These same operations in Costa Rica would cost 45 to 65% less than in the US, and would not require such long flights from most parts of the US. What are you waiting for? Save some money, I guarantee your insureds will love you for it.

Malaysia would be 60 to 80% less, but why go there when you can go to Costa Rica?

According to Woodman, medical tourism (travel) is a Band-Aid for the country’s dysfunctional health care system.

Woodman told Salon, “I don’t think you can penetrate this with philanthropy. It’s gonna be baby steps all the way. But in the meantime, medical tourism is a really important option.”

Woodman also said he did not like the term “medical tourism” because it is not a vacation. You may have noticed that I use the term “medical travel” instead. It is travel for medical purposes, and if there is tourism component to it, it is incidental to the reason for going in the first place.

Patients who cannot afford dental work, IVF or orthopedic surgery in the US, Woodman said, should consider travelling abroad. If their operation or treatment is expected to cost them $6,000 out of pocket, they will save money — even with the plane ticket.

Oh, by the way, that Minnesota couple spent, get this, only $235 for the IVF, not including flights. With such reasonable cost savings, it would be a no-brainer for workers’ comp to do the same.

But some people are stupid, ridiculous, and non-starters in my book.


Foreign-born, US-trained Physicians in Medical Travel vs US-born, Foreign-trained Physicians Practicing in the US and Foreign-born, Foreign-trained Physicians Practicing in the US

Those of you in the Workers’ Comp space have probably read my earlier posts extolling the benefits of medical travel, and promoting its implementation into workers’ comp.

Yet, in all those posts, hard evidence of the quality of care provided by physicians in these destinations was not presented.

However,  there is evidence that foreign trained, US  born doctors practicing in the US, provide as good as or better care than that provided by graduates of US medical schools, according to a recent study mentioned over the weekend in a post by Peter Rousmaniere, in his blog, Working Immigrants.

From this data, it may be possible to suggest that foreign-born doctors, trained in US schools provide the same good or better care than their American-born classmates, when they return to their home countries and work in medical travel facilities.

Before beginning to write this post, I tried to research some data on this, but was unable to find any recent information. However, it is well known that there are considerable numbers of foreign-born, US trained and Western trained physicians in medical travel facilities, which is one key factor in choosing to go abroad for medical care.

As Peter reported, among the 12.4 million workers in the health care field in 2015, 2.1 million, or 17% were foreign born. Of these, the foreign born accounted for 28% of the 910,000 physicians and surgeons practicing in the US. 24% of that number are in nursing, psychiatric and home health care.

How many of the foreign-born physicians trained in the US return home is not certain, but given the fact that many foreign born, foreign trained physicians have a hard time gaining access to practice in the US, it is not difficult to ascertain that those who do not enter the US end up working in their home country. In order to practice in the US, they must pass tests by a special commission and enter a residency program, even if they have done them before.

How many foreign trained, US born physicians practice in the US? According to Peter, about 25% of practicing physicians graduated from foreign medical schools. About a third of them are Americans. They are more likely, Peter says, to practice in rural and poorer communities, and are overrepresented in primary care. Given the physician shortage that I and others have commented on, there will be a need for more foreign-born doctors, and perhaps, more US trained, foreign-born doctors to work in medical travel facilities.

The Education Commission for Foreign Medical Graduates (ECFMG) gave roughly 10,000 certifications in 2015. 30.9% were issued to US citizens, 18.9% were issued to citizens of India and Pakistan, and 7.9% from Canada.

The states with the highest percentage of practicing physicians who graduated from foreign medical schools are New Jersey (40%), New York (38%), and Florida (35%).

Most of the New Jersey physicians no doubt practice in the Metropolitan New York Area, given the state’s proximity to NYC. And Florida has a large percentage given the demographics of that state.

So, if foreign-born, US trained physicians are ok for treating injured workers here, why can’t their fellow countrymen do the same back home if an injured worker, or his employer choose that as an option to expensive surgery at an American hospital?

Don’t tell me there is a difference, because there isn’t. It is only ignorance and prejudice that prevents foreign-born, US trained physicians from treating injured workers in medical travel facilities. That is another problem our health care and workers’ comp systems need to deal with.

Words and Phrases: Global Healthcare or Whatever You Want to Call It

This past Saturday, while waiting for power to be restored in my area due to a pesky lizard’s venture where lizards don’t belong, I was able to use my cell phone to read some posts on LinkedIn.

I came across a discussion by three of the top medical travel personnel answering the question, “Is the term “Medical Tourism” obsolete?”

This discussion thread was begun by Stella Tsartsara, and followed by Ilan Geva and Elizabeth Ziemba, including yours truly, who put his two cents into the conversation.

Since Stella has given me her approval to use her comments, and I suspect that Ilan and Elizabeth would not mind, I am going to quote them verbatim here for the reader to digest. There will be some names that I will leave out, because one, I have not contacted them, and two, they were mentioned in passing by the individual who I am quoting.

Stella I. Tsartsara:

“I see Elizabeth Ziemba talking about carrying capacity of HC systems. XXXXXXXXXXXXXXXXXX told me half of the international projects I do have nothing to do with Medical Tourism, XXXXXXXXXXXXXX told me we are dealing with “International Healthcare” anymore, we are passed the term “Medical Tourism ” probably instigated by people traveling to another destination for (cheaper) surgery not covered by their insurance where the “patient” had time to do some sightseeing. But once the demand came to more serious interventions like heart surgery then the only organization needed was a reliable MTF and good research from the patient to guarantee results. Here the “tourism” is at the 4-5th place after doctor, hospital reputation, waiting list time, safety, post- surgery follow up, price and cost reimbursement from insurance.

Now with the Cross Border Healthcare and the Trade in Services Agreement (TiSA) Wikileaks revelation on the globalization of healthcare officially by the states, things take a completely new turn and the fact that we are talking about Medical Tourism is raising some eyebrows. Or at least it should be split from Healthcare delivery.”


Stella I. Tsartsara:

“I have no possibility for edit, I rephrase here that XXXXXXXXXXXXXXXXXX told me some time ago that her projects deal with international healthcare mostly which is a healthy sign of evolution in the industry although XXXXXXXXXXX says this word does not exist either, to which of course I agree.

Terms are the beginning of taking the trend seriously by the demand. It’s about shaping policy in the end.”

Ilan Geva:

“Stella, I think that the term Medical Tourism was pushed upon us by an association. The fact is no one, except our circle of Professionals, is using it or cares about it. In the effort to differentiate and stand out, many started to use Medical Travel, Global Healthcare…whatever. Patients don’t really care what you call it, they have a need or a want that requires a solution. Many of them are not looking for the “Tourism “aspect of a medical issue. Have you noticed that even the MTA is not using their name as much as they used to? They are now pushing the GHA brand.

Is that an indicator that medical tourism is dead? Who knows, and frankly, who cares? Globally, there are enough tremors in the healthcare sector, enough to guarantee continued movement of patients from one region to another. Maybe we should start calling it “Medical Voyages”?”

Elizabeth Ziemba:

“Thanks for starting a very interesting conversation, Stella. The term “medical tourism” isn’t dead yet because it is still the top search term in the sector and is heavily used by the media. But the sector itself has outgrown the term. I will be giving a presentation at the IMTJ/World Health Care Congress about this very topic. The sector is changing but it is hard to get away from “medical tourism” when SEO rules. I must admit that the name of my company, Medical Tourism Training, was selected because of its SEO and familiarity to people. Even now, people react to it favorably even though I hate it. Time to look past the label to the substance.”

Stella I. Tsartsara:

“Ilan Geva “medical tourism” is not dead and maybe never dead as there are interventions where tourism plays an important part and here individual consultants have a bigger profit margin. But definitely movement of patients for elective treatment is not and cannot be called this way.

In EU we call it “Cross Border Healthcare” because we established the Institutional parameters for its organization and delivery.

This is what is lacking from an international perspective for the term to have a meaning. By the way trained eyes in institutional development like XXXXXXXXXXX will see immediately that the TiSA is exactly the same (with 2 additions on insurance and compulsory post-surgery monitoring & liability) with the EU Directive 24/11/EC on the Cross Border Healthcare in EU.”


“I have used “Medical Travel” in my posts, but for the purpose of selecting a category to place them in, or to tag them when I write, I use both “Medical Tourism” and “Medical Travel”.”

Stella I. Tsartsara:

“Elizabeth Ziemba & Richard Krasner, MA, MHA I tend to agree more with Ilan Geva on the matter. However as I said there will always be room for the “tourism” side for hundreds of treatments where tourism plays a very significant part like Medical SPA, cosmetic surgery, diagnostics, dental etc, although still I do believe that it’s not a priority. What Ilan said it’s a revelation for the “association”. Who else would give international care such a limited meaning maybe pushed by its operators back then.

But what is coming ahead e.g. Institutional and Regulative development of international healthcare (among public hospitals as well) has absolutely nothing to do with “tourism”. We have to set things straight if we want to be taken seriously by those who will be in our path in the consultation activities for its future development. Those who were (are still) building the TiSA are not going to look or refer to “medical tourism”.”

Stella I. Tsartsara:

“I also have the impression that something is moving in layers that are not yet visible to us, on the management of this new trend. I believe that actors are organizing themselves differently and as there is not yet a market (it’s still a taboo internationally exactly because it involves also public HC, we in EU have solved this but it’s not the case at global level) and the demand is still hybrid, there is no business development and marketing yet of this new consulting set of skills and delivery. But very soon we are going to see a new type of developers in this perspective catering for the state development of international HC. I have proposed years ago through this group the organization of such Groups combining inevitably many specializations and some do exist already run by big Hospital Groups.”

It would seem there is not clear consensus on what term is appropriate for the activity of leaving one’s home country and travelling to a second country for medical care, no matter what the reason for travel may be.

If, as Stella said, it was for heart surgery, doubtless the patient would not be doing much sightseeing post-operation. Yet, on the other hand, if it was for less invasive, and less stressful surgeries and procedures, and if the patient was cleared by the physician and physically able, then the tourism part would apply.

The revelations by Wikileaks of the negotiations on the TisA is no doubt a concern to the entire industry, whether one calls it medical tourism, medical travel, health tourism, health travel, etc. The result is the same. Knowledge of the existence of such an agreement may forestall that agreement being finalized, if not totally scrapped altogether if the right individuals lead a campaign against it in member countries.

Such was the case with Brexit, and such was the case with the 2016 U.S. elections that Wikileaks had a hand in derailing.

The solution, therefore is a stronger effort on the part of all stakeholders to develop strategies, plans, and standards to regulate the industry and to promote it effectively. Relying on an association we know is unreliable is not going to work. Before TiSA is tossed aside like the TPP, or the Paris Climate Treaty by nationalistic dunderheads, the industry must do more.

P.S. The rest of the thread can be seen here: https://www.linkedin.com/groups/4304089/4304089-6368077962927050755

Health Care Top US Employer and What It Means for Medical Travel

Back to the real world of health care, et. al.

Last week, The Atlantic magazine reported that the US health care industry has supplanted manufacturing and retail to become the largest source of jobs in the US.

The article, by Derek Thompson, reports that for the first time in history, in the last quarter, there are now more jobs in health care than in the two industries that were the leading job engines of the 20th century.

According to Thompson, in 2000, there were 7 million more workers in manufacturing than in health care, and at the beginning of the Great Recession, there were 2.4 million more workers in retail than in health care.

Thompson says that there are three main drivers of the boom in health care jobs.

  • First, Americans as a group are getting older. By 2025, one-quarter of the workforce will be older than 55 (your humble blogger). This will have doubled in just 30 years. It will have a profound economic and political impact, such as declining productivity and electoral showdowns between a young, diverse workforce and an older, whiter retirement bloc. [True in the last election.] The most obvious effect of an aging population will be that it needs more care, and more workers to care for them.
  • Second, health care is publicly subsidized. The US spends hundreds of billions of dollars on Medicare, Medicaid, and benefits for government employees and veterans. [The recent tax bill passed will make substantial cuts to many of these programs, or outright privatize them.] The US also subsidizes private insurance through tax breaks for employers who sponsor health care.
  • Third, two of the most destabilizing forces for labor in the last generation have been globalization and automation. They have hurt manufacturing and retail by offshoring factories, replacing human arms with robotic limbs, and dooming fusty department stores. Health care is resistant to both. While globalization has revolutionized supply chains and created a global market for manufacturing labor, most health care is local. A Connecticut dentist isn’t selling her services to Portugal, and a physician’s receptionist in Lisbon isn’t directing her patient to Stamford. [I take exception here, as many of you will too. It seems Mr. Thompson has not heard of Medical Travel, both inbound and outbound, and therein lies your problem.]

Finally, the growth in health care employment is more located in administrative jobs than in physician jobs. The number of non-physicians has exploded in the last two decades. Most of these jobs are administrative such as receptionists and office clerks. It is not clear that these workers improve outcomes for patients.

Robert Kocher, a senior fellow at the Schaeffer Center for Health Policy and Economics at USC said the following, “Despite all this additional labor, the most meaningful difference in quality over the past 10 years is the recent reduction in 30-day hospital readmissions from an average of 19 percent to 17.8 percent.”

One other point Thompson notes, is that categories like retail and health care are imperfect approximations, and that some categories are too restrictive, and some are too broad. He points out that there are more jobs in leisure and hospitality than in health care. [Which would explain why some in Medical Travel are more like travel agents, than medical professionals.]

So, while there is good news about the position of health care employment in the US, the downside is, at least as far as Medical Travel is concerned, that globalization may not have as much of an impact on health care as I, and others have thought, and that portends bad news for the industry.

Ashley Furniture and Medical Travel, part 2

As promised last month, here is the Spotlight article from Medical Travel Today.com about Ashley Furniture’s foray into Medical Travel for their employees.

In case you missed it, here is the link to part 1 of the article.

Foreign Patients Get Liver Transplants in US Hospitals First

ProPublica, those lovely folks who published several articles some time back on workers’ comp, are at it again.

This time, they are focusing their ire on how foreign patients are getting liver transplants at some US hospitals ahead of Americans waiting for such transplants.

The story, published yesterday, was co-published with a local Fox station in New Orleans.

From 2013 to 2016, New York-Presbyterian Hospital gave 20 livers to foreign nationals who came to the US solely for a transplant, essentially exporting the organs and removing them from the pool of available livers to New Yorkers.

Dr. Herbert Pardes (I was familiar with his name from living in NY), wrote that, “Patients in equal need of a liver transplant should not have to wait and suffer differently because of the U.S. state where they reside.”

Dr, Pardes was the former chief executive, and is now the executive vice president of the board at New York-Presbyterian.

Yet, according to the story, Dr. Pardes left out NY-P’s contribution to the shortage, as stated above from 2013 to 2016.

These 20 livers represent 5.2 percent of the hospital’s liver transplants during that time, which was one of the highest ratios in the country.

ProPublica reported that unknown to the public, or to sick patients and their families, organs donated domestically are sometimes given to patients flying in from other countries, who often pay a premium. Some hospitals even seek them out.

A company from Saudi Arabia said it signed an agreement with Ochsner Medical Center in New Orleans in 2015.

The practice is legal, according to the story, and foreign nationals must wait their turn in the same way as domestic patients. The transplant centers justify this on medical and humanitarian grounds, but at a time when we have an Administration touting “America First”, this may run counter to the national mood.

The  director of the transplant institute at the Mount Sinai Hospital in New York, Dr. Sander Florman, said he struggles with “in essence, selling the organs we do have to foreign nationals with bushels of money.”

Between 2013 and 2016, 252 foreigners came to the US purely to receive livers at American hospitals. In 2016, the most recent year for which there is data, the majority of foreign recipients were from countries in the Middle East, including Saudi Arabia, Kuwait, Israel and the UAE. Another 100 foreigners staying in the US as non-residents also received livers.

At the same time, more than 14,000 people, nearly all Americans, are waiting for livers, a figure that has remained very high for decades, they report. By comparison, fewer than 8,000 liver transplants were performed last year in the US, an all-time high. National median wait time is more than 14 months, and in NY, the time is longer.

In 2016. more than 2.600 patients were removed from waiting lists nationally, either because they died or were too sick to receive a liver transplant.

All this is happening at a time when the party in power is seeking to take health care away from those who recently received care for the first time in a long time from the ACA, and at a time when the medical travel industry is focused not on transplant surgeries, but on boutique treatments and surgeries for wealthy or upper middle class Americans to go abroad for bariatric, plastic or reconstructive surgery, knee surgery, dental care, etc.

And yet, when the very idea of medical travel is broached in the medical community, it is disparaged and discouraged by physicians and others as unsafe, impractical, and not worth the effort, Obviously, it is well worth the effort on the part of foreign patients to come here and take organs meant for Americans, so why not allow Americans to take their organs?

Is it because the hospitals that supply these organs to foreign patients are making huge sums of money, and the poor schnook American with liver disease (or kidney disease, as in the case of yours truly) must die so that an American hospital can improve its bottom line?

It is high time to cut the crap and promote medical travel the right way and for the right reasons, not only for those who can afford it, but those who need transplants and can’t get them here.

That is the true nature of the globalization of healthcare…a two-way street.


The Fork in the Road in Medical Travel

Returning to the main theme of this blog, I came across the following insightful article by Ruben Toral last week that posed the question, “Is Medical Tourism Dying a Slow Death?”

As someone who has been interested in opportunities in Medical Travel for some time, and  disappointed in not being able to elicit interest in my idea for Medical Travel, I was interested in seeing what Ruben had to say, and to see if it measured up to my views of the industry, as I know it.

According to Ruben, the industry exhibits the traits of a typical product/business cycle, whereby the first and fast movers establish leadership by developing and commercializing the concept, then late adopters pile in to get in on the action.

He goes on to decry the same speakers at every medical tourism event around the world talking about the same things, which is enough to hit the snooze button and go back to sleep.

He also laments the lack of innovation, and says that key players are just trying to manage the slow growth rather than investing in the next wave.

VC investors, Ruben says, talk of getting burned on medical tourism investments that simply cannot scale like other businesses, because, as they quickly learn, healthcare is a different animal than retail and you burn through a lot of cash fast trying to buy eyeballs and audience.

And investment analysts ask the same question after pouring through hospital financial reports and see how hospitals are managing and protecting profit margins: “Where’s the growth?” And even large meeting and events companies are not “flogging medical tourism” because attendance and interest is way down.

So, is this the beginning of the end or the inflection point for medical tourism?, Ruben asks. For his part, he does not know, but if it is not the beginning of the end, or an inflection point, it is most certainly a fork in the road.

Where it goes from here is as good a guess as mine and Ruben’s, but it is up to those who are serious and dedicated to growing the industry to regroup and start again to build interest and enthusiasm for medical travel, and to address some of the glaring issues facing the industry.

But that won’t happen until there are changes within and without the industry…in technology and in strategy.