Health Business Blog

Check out Change of Shift, the nursing blog carnival, at Emergiblog.

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Compared to most medical specialties, radiologists make more, work less, and have less stress. There are always plenty of jobs available –demand has continually outpaced supply. Why, then are radiologists so paranoid about losing business to other specialties? Here’s a prime example of this tendency from AuntMinnie (Radiology still has a chance to control cardiac CT)

In the decades-long struggle between radiologists and cardiologists over control of new cardiac imaging technologies, the heart specialists have an undefeated record. But history may not repeat itself with respect to cardiac CT angiography. In fact, the edge may be shifting to radiology, according to imaging utilization expert Dr. David C. Levin…

Levin contends that radiologists recognize that the need to offer CTA and compete with cardiologists is vital to the overall health and prosperity of the radiology profession. “If we lose cardiac CT and MR to cardiologists, then neurologists, medical oncologists, orthopedic surgeons, and urologists all will want to start offering specialized CT and MRI procedures,” Levin said…

“Collaborating with a cardiologist can at times be like collaborating with a rattlesnake,” Levin quipped. “But it is better than rolling over, playing dead, and hoping that the rattlesnake won’t bite you. Don’t be intimidated by the propaganda of the American College of Cardiology. With the advantages that exist for radiologists, dominance in coronary CTA is for the radiology profession to lose.”

Lovely, fellas.
It kind of reminds me of the Kinks song Destroyer (especially the last line)

Girl, I want, you here with me
but I’m really not as cool as I’d like to be
’cause there’s a red, under my bed
and there’s a little yellow man in my head
and there’s a true, blue, inside of me
that keeps stoppin’ me, touchin’ ya, watchin’ ya, lovin’ ya

Paranoia, deep destroyer. Paranoia, deep destroyer.

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As economic growth continues in Asia and per capita income rises, traditional threats to health like poor sanitation, malnutrition and lack of medical care are being beaten back. Unfortunately self-inflicted woes –smoking, alcohol, inactivity, poor eating habits– are a growing menace. There are 300 million smokers in China, the same as the whole US population. Many will die from smoking-related illnesses.

It’s a real shame from a human standpoint and it will also cost the region a fortune in foregone productivity.

I wonder whether we’ll see high tobacco taxes and outright bans on smoking. I bet some governments would outlaw tobacco if they could find a way to avoid an insurrection and if government officials could get over their own addictions. Having seen how quickly countries like Italy and France have tackled smoking, I’m optimistic for Asia, though it may take a while longer.

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The blogosphere is about to light up over the lead story in today’s Boston Globe regarding the “unmasking” of Dr. Robert Lindeman, aka Flea. I’m planning to stay out of the debate.

Let me just say that Rob is a fantastic pediatrician and a wonderful human being. If you have kids and live anywhere near Natick, MA you should consider choosing him as their physician.

I just wish he had blogged under his real name rather than anonymously. The world is a poorer place now that his blog is gone.

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Despite its low cost base, China isn’t going to take over drug manufacturing just yet. The Chinese government was embarrassed enough by recent scandals to give a death sentence to the former head of their equivalent of the FDA for taking bribes. It’s obviously a harsh punishment, but so is dying from tainted Chinese cough syrup.

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One of the great things about the Wall Street Journal (and there are many) is its strict separation of the editorial page from the news. Whereas the editorial page and many of the Op-Eds are strident and ideological, the news pages offer as close to an objective voice as you’re likely to find.

There is, however an indirect relationship between the two parts of the paper. In particular, I enjoy it when the sober, objective news staff writes about an issue that’s been treated ideologically on the Op-Ed pages.

There’s an example today on the front page: “Delicate Operation; How 10 People Reshaped Massachusetts Health Care,” which describes the hard work the Connector is doing to try to make near-universal health care a reality here.

The Connector board offered, in microcosm, a look at the collision of interests — business, labor, medical professionals and needy patients — that has derailed decades of efforts to reform the U.S. health-care system. When it comes to health-care reform, everyone’s second choice, after their own plan, has been the status quo.

In Massachusetts, board members did something unusual, finding ways to compromise on some of their most cherished positions and reach common ground. As a result, Massachusetts is poised to become the first state to achieve near-universal coverage. Registration for the new insurance plans began May 1.

Unlike Washington, the Connector compromised successfully because it was expected to, stepping in after a long struggle by state lawmakers to create a plan supported by all major parties. Says Joseph Antos, a health-policy expert at the conservative American Enterprise Institute: “They have a responsibility. They have to produce.”

I think that’s about the right take, and it’s not accidental that a “conservative expert” is chosen to comment.

Contrast that with a Journal op-ed piece (Intensive Care for RomneyCare) I commented on a while back. In it, Pacific Research Institute’s Sally Pipes declared:

[L]ess than a year after passage, RomneyCare is in the intensive care unit, soon to be wheeled into hospice.

Pipes and her buddies are really hoping the plan fails, because it doesn’t fit their pristine ideological view. Fact is, it’s ideologically unsatisfying compromises that will be needed to evolve the system toward sanity, and not just in Massachusetts.

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Check out the latest edition of the Health Wonk Review blog carnival at The Sentinel Effect.

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Here’s the transcript of my recent podcast interview.

David Williams: This is David Williams, cofounder of MedPharma Partners and author of the Health Business blog. Medical care in the US costs a fortune. In the past few years uninsured and underinsured Americans have been venturing to places as far away as India and Singapore for surgery and other treatments. The care’s often excellent, prices are low, and even surgeons are customer service oriented. I spoke earlier today with Josef Woodman, author of Patients Beyond Borders: Everybody’s Guide To Affordable World Class Medical Tourism. Listen in and hear what he has to say.

Joe, tell me how you got interested in international medical travel.
Josef Woodman: Three and a half years ago my father suddenly announced that he was heading to Mexico to get a mouthful of teeth restored. He was 72 at the time. I had a visceral reaction. I was concerned about treatment in a shoddy clinic with rusty instruments and an untrained doctor, so I followed him out there and found exactly the opposite to be true. He had located a very clean clinic with a board certified physician, a dentist, really a quality staff, state of the art instrumentation. In fact I think the first panoramic Xray I’d ever seen in a dentist’s office was there.He saved $11, 000. That includes the cost of the trip and a month there. I came back home and found friends with the same reaction when I would tell them the story where I had gone, what I was doing. These friends had the same reaction I had when I let them know what the real story was. They would follow me out the door looking for his email address. So the publisher part of me just couldn’t resist the notion of a book on the subject. That started a three-year project which resulted in Patients Beyond Borders.
David: Interesting. So it’s interesting that you were involved more in the health care and publishing space than your father seemed to be, the trailblazer. How did he find out about the idea of going, not necessarily overseas, but going to another country to have dental work done?
Josef: He is a very practical person, and when he was quoted some price, it just dropped his jaw. I think he was quoted something like $24, 000 for this restorative dentistry. He just simply couldn’t afford it. He had been in Mexico and seen some of these clinics, and he was curious about them. Three and a half years ago he was something of a pioneer, but there were enough websites in English that he could get through.
David: Now, I sometimes hear this term medical tourism, which you use a little bit in your book but not so much. I’m wondering where that notion of medical tourists came from, and also if you have a preferred term other than that?
Josef: Well, actually the term grew out of India when the Indian government was trying to court medical travelers. That is a fairly recent term. The term medical tourism is probably not more than two years old. In fact it grew out of India after we started our research. On the one hand we were happy to see it labeled. On the other we considered it a misnomer, which is why you don’t see it much in the book. We actually mentioned the term in the book as a misnomer.We prefer international medical travel. The reason we feel it’s a misnomer is because it implies tourism and leisure time and recreational time. We feel they’re separate issues. We don’t recommend that anyone takes a vacation we think it’s best for people to take care of their bodies, take care of their health, not think of it in terms of tourism any more than a business traveler is thought of as a business tourist. You never hear the term business tourist. People have a goal. They meet their goal. They come on home, and then maybe if they saved some money, which they usually do, they can salt that away and when it’s time to a nice trip, they and their companion can go on a nice trip together. It’s separate issues.
David: Did you have a prototypical patient in mind when you wrote the book?
Josef: There are two types of medical tourists. One is the cosmetic surgery crowd and the Beverly Hills, Chevy Chase crowd. They head down to Brazil. They’ve got their own network. They spend probably twice and three times the amount they’d spend in America and come back home and brag about it. That’s a relatively low number. That’s not the crowd that we addressed.The crowd that we saw repeatedly in these hospitals were part of the 46 million uninsured and another 30 million under or partially insured. These are folks that are aging into expensive medical procedures, and they find themselves financially challenged. They’re in the middle class. They’re in the upper working class. They don’t want to have to sell their home or sell their small business just to pay for an expensive procedure.
David: So when you talk about underinsured patients, that sounds like patients that have some kind of insurance, and they’re still finding it worthwhile to go overseas?
Josef: Oh yeah. Underinsured can involve a number of circumstances. Technically anyone with a dental plan is underinsured, and there’s a 120 million Americans without dental insurance. For those who have dental insurance, they’re technically underinsured because, especially aging patients, your flesh is going to outlive your teeth. Almost no dental plan covers any of the major noncritical procedures, such as restorative surgery. So technically you’ve got so many exclusions with a dental plan that you’re underinsured.Same thing is true with, let’s say, a hip replacement, an orthopedic procedure. Unless a physician defines that as being critical care, you get to pay for that yourself even if you have insurance. It’s excluded. Also a lot of people have preexisting conditions, and that gets excluded.
David: Now, what about patients who aren’t underinsured but who are well insured? Are there any insurance companies that are actually looking to overseas providers as a way to reduce costs or to increase quality or convenience?
Josef: Well, our research shows us that so far there’s just a couple or three insurance companies with very specific plans, but look for big changes within the next year.
David: What are some of the common misconceptions that people have about international medical travel?
Josef: Well, as far as the misconceptions, there are three misconceptions that I’ve seen and that we’ve struggled with as the industry matures.One is that it’s somehow a gimmick, that you can’t get something for nothing, or for a 30%80% discount. There must be something. Either the customer care isn’t as good or you’re actually going to get your surgery in a mud hut. So that’s a fairly common misconception, which is born of typical American xenophobia shall we say. People just aren’t familiar with other cultures, and can’t believe that the healthcare would be on par in other countries.

Another common misconception is one we alluded to, which is what I call sort of the fun and sun misconception. When we first started our research the web was filled with all kinds of promotion from countries, from health travel brokers. “Get your cosmetic surgery and lie on the beach for ten days and then come on home.”

So the whole notion of medical tourism as being somehow having surgery and going on a vacation was much more popular. You don’t really see much talk about it now as the media grows up, and begins to address some of the more important aspects of international medical travel.

And the third misconception is outsourcing. And people feel that somehow medical travel is all about outsourcing. And what they need to know is most of the hospitals that were built to attract the international medical traveler in Thailand, in Singapore, the hospital that’s just being built in Dubaihuge complex of hospitals therethey don’t even have the medical traveler in mind. Most of the international medical travelers are from Europe, they’re from the Middle East, they’re from Africa, and Eastern Europe.

And so it’s really not about outsourcing. Doctors aren’t leaving this country to go practice elsewhere. And huge industries aren’t cropping up that match the traditional definition of outsourcing.
David: What are some of the mistakes that people make when they’re planning treatment overseas?
Josef: Well, that’s a good question. We sometimes refer to our book as the result of a thousand mistakes that patients have made. Fortunately, very few of those mistakes are life threatening.The main mistake a patient makes is being uninformed or being illinformed. And so to the extend that a patient is informed, they’re going to have a successful medical trip if they take the time to look into, for example, the accreditation of a particular hospital, success rates, and the number of surgeries performed, which questions to ask your physician, how to handle discomforts and complications after you get home.

Make sure that you inform your physician before you leave, and make sure you leave your destination after your precedence with all of your medical records. And we’ve got a dos and don’ts chapter that covers most of the common mistakes that people can make.
David: Now, you have a whole section of the book that talks about the most traveled health destinations. And with the various countries, you list some of the key clinics there with their information, about them, and prices that they charge, and so on and I’m wondering how were you able to compile that information?
Josef: Well, we put a team together, an editorial and a research team, and we spent almost two and a half years compiling and writing the book. Naively we started with around 50 countries. And then we began to wonder, how in the world do we assess these countries?And long story short we began to look at the accreditation within a giving country. We discovered JCI (Joint Commission International), which is an arm of JCAHO that accredits hospitals overseas. There’s now 117 hospitals accredited abroad through an American agency. Out of say, around 1, 000 hospitals that we looked at, we vetted those hospitals in terms of in country accreditation, in terms of the cultural transparency, and the kind of experience that especially an American traveler would accept.

And then when we pared the list down, we sent surveys out to those hospitals, and depending on their answers to those surveys, if they answered them at all, we then narrowed the list down to hospitals that you see featured in the book. All of them had to have an international patients’ center where there was English spoken, they all had to at least respond to the survey, and they all had to have reliable accreditation.
David: Now, do you have a favorite destination of all these countries? I’m sure it would depend on the particular treatment that you needed, but are there any ones that stand out that you particularly like?
Josef: In general treatments for dentistry and cosmetic surgery can be handled on the Western Hemisphere, either in Mexico, or Costa Rica, or Brazil. And we recommend for people who are looking for procedures involving cardiovascular, orthopedic it may be best to endure that 24 hour, 30 hour trip to Singapore, or Thailand, or India, or Malaysia for those more invasive surgeries.
David: Now I noticed in thumbing through the list of the different countries and the different centers that it seems like some governments have been much more proactive than others in trying to attract the international medical travelers. And in particular, I noticed the contrast between Brazil and Singapore. Could you talk a little bit about that?
Josef: A lot of the success of international medical travel does have to do to the extent the governments, the accreditation agencies, and frankly the tourism bureaus want to attract that international traveler. So in Singapore, for example, the government oversees all four of the main health care networks including two of the private networks, Parkway and Raffles. These are huge medical institutions that usually don’t answer to government. Singapore’s done a great job of corralling that and bringing a lot of standardization to international medical travel.Brazil, on the other hand, the government for a number of reasons eschews medical travel, especially for the main reason people go down there which is cosmetic surgery. There’s not a lot of cultural transparency. If you don’t speak Portuguese, chances are you’re going to be out of luck, unless you go to one of the very few hospitals that cater to the international traveler.

India, for example, is a huge proponent of medical travel. In Thailand they saw it as one of the solutions to the falling baht in the late ’90s, and they identified medical travel as a big revenue source and targeted the many expatriates in Thailand and in Bangkok to come to Bumrungrad. That’s how Bumrungrad got it’s start, was through marketing to the expatriate crowd. Then they discovered lots of Europeans and Middle Easterners coming over. After 2001 when folks in the Middle East weren’t welcomed in the United States, Bumrungrad was flooded with those folks. Now they’re marketing to a more Western audience including America.
David: Well, one of the things that really struck me in reading the book was the way that physicians overseas, even some of these surgeons, are quite accessible. It mentioned something that was a real shock to me, which was that they would typically want to communicate by cell phone with a patient even when the patient was first in the country and then after the surgery and to follow up on them. Can you talk a little bit about what somebody might expect in terms of how they work with an overseas physician compared to what they’re used to in the US?
Josef: Yeah, I have to tell you if I hadn’t seen this with my own eyes and actually hadn’t been a medical traveler myself, I just wouldn’t have believed it. My first experience was when I traveled to India. There was a couple from Wisconsin that I interviewed and followed for months after they returned home. They were consulting regularly with one of the top surgeons in Asia, a man named Vijay Bose in the Apollo Network in Chennai in India.I actually thought that this man was almost a charade for what he perceived as a reporter when I was there. I found out later that he spends probably 25 percent of his time talking to his patients directly on the telephone, preprocedure and postprocedure. These guys just live with their cell phones in their hands, with text messaging and voice. They have a very close tie with their patient. In addition, most of them are more than willing to talk with a US physician should there be any discomforts or concerns or, God forbid, complications upon a patient’s return.
David: Now one question I was going to ask that you made me think about was how does physicians in the US feel about their patients going overseas? It sounds like the overseas physicians are willing to follow up with the US physicians. Is the patient likely to get written off by their US doctor if they go overseas for treatment?
Josef: I feel bad for physicians. I feel like they’ve got a raw deal in the US. They now find themselves unable to compete in a way that they would probably like to. They find themselves rushed and forced into a lot of decisions outside of their control by their hospitals, by the insurance bureaucracy. It’s a tough place to be. So many physicians are either uninformed about health care overseas and just the quality of the health care and the quality of customer service, or they’re competitive and intimidated, or both.So a patient who queries his or her physician or specialist is not likely to get a lot of support, and that’s understandable.
David: Now, other than reading your book, are there some other resources that you recommend for patients who are considering international medical travel?
Josef: If I were a patient, I would certainly start with JCI and get familiar with some of the better hospitals. JCI has a listing of hospitals throughout the world that have received their seal of approval, their JCI accreditation. There are some good websites. They won’t give you alpha to omega information, but you can piece it together. There’s a site called medicaltourism.com. There’s Medical Nomad. It’s medicalnomad.com. Those folks have compiled information for the medical traveler. No doubt there’ll be more books after this one broke its ground, after “Patients Beyond Borders.”
David: Now, Joe, what’s going to be next for you after writing this book and getting highly involved in the whole international medical travel area? Is there a “Patients Beyond Borders II”? Are you moving on to something else? What do you think?
Josef: Well, certainly there’s a second edition. We had to get the book out, and we culled the information down to 22 destinations in 14 countries, which gives people a really good start for the common procedures. However, there are specialty hospitals. There are centers of excellence within the hospitals that we featured that we’re learning about.So in the second edition, which we expect to be at least 50 percent bigger than the first edition, we want to go deeper. People don’t need more hospitals. They need better information about these centers of excellence. So if they had a certain type of cancer, they know which two or three hospitals have the very best cancer centers. We want to dig deeper into research. And of course there are more hospitals emerging.
David: I’m been speaking today with Josef Woodman, author of “Patients Beyond Borders: Everybody’s Guide To Affordable, WorldClass Medical Tourism” published by Healthy Travel Media. Joe, thanks very much for speaking with me today.
Josef: Oh, thank you. It was good to be here.

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Check out Grand Rounds, the best of the week’s medical blogging, hosted by From Medskool.

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Massachusetts’ Commonwealth Health Insurance Connector is doing its best to ensure the availability of affordable, high-quality health plans. For young adults, they’ve opted for an enhanced version of the existing student health plans, which have been mandated for almost 20 years. The plans are cheap: as low as $119 per month without drug coverage.

There’s a catch, though. The plans have annual coverage caps of $50,000 or $100,000. That’s higher than the $25,000 to $50,000 caps of the student plans, but it won’t take a seriously ill young adult (or their premature baby) to run up a bigger bill than that in Beantown.

Patricia Walrath, co-chair of the Legislature’s Health Care Financing Committee told the Boston Globe:

We thought this was one place where we could be a little experimental, because they are a very low-risk population.

But the Access Project thinks differently and issued a report critical of the plans. Plan co-author Stephen D’Amato says:

[T]he main purpose of insurance is to protect people in those rare instances when you have huge costs. Allowing these caps is duplicating a mistake that was made nearly 20 years ago. It’s going to destroy some lives

In a perfect world –or actually in any other OECD country– $119 per month would be enough to pay for comprehensive coverage for a young adult. Here, though, it isn’t. As a result, there’s a tradeoff between an affordable premium, coverage for routine services, and coverage for catastrophic costs.

I’ve written before about Mini-Meds –policies that offer limited coveraged, with caps much like these new Massachusetts plans. In some ways they are odious –almost the opposite of insurance– but they do provide access to the health care system and take away the worry of being saddled with $10,000 or $20,000 in medical debts. A debt like that can seem almost as catastrophic as a $1 million debt to people of limited income.

I don’t object to the capped plans for young adults. First, keeping the premiums somewhat reasonable will increase compliance with the mandate and increase the attractiveness of living in this state. Second, if debts get too high there’s always bankruptcy protection. Young adults have time to start over and since the hospitals will have such a high percentage of insured patients they should be able to suck up some of the losses without whining too much.

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