Solutions: “Sicko” Shows the Problem

By Paul Gahlinger

Is medical tourism the solution?
by Paul Gahlinger
gahlingermedtourism.jpgIn 1993, Tony Ramirez went to the small hospital at Fall River Mills, in northern California with what he suspected was a broken arm. He and his brother ran an auto-body shop-successful enough make a living, but not quite sufficient to buy private health insurance. The X-ray showed a fracture running into the wrist bones. A cast would not be enough; he needed a surgical procedure to have the bones wired together for proper healing. Tony would have to pay the total cost, likely to be over $5,000. Then the emergency department doctor, in a conspiratorial tone, suggested an alternative. He could put the arm in a temporary cast, give him some heavy-duty painkillers, and Tony could take a bus to Tijuana, just over the Mexico border, where he could have the same procedure done much cheaper.

I know about this case because I was the doctor covering the emergency room that day. The conspiratorial tone was needed because what I did could have got me into trouble. {quotes align=right}Hospitals, and all their specialist physicians, thrive off surgery and high-end procedures. Some even support primary care clinics just to have a pipeline feeding patients into their more lucrative operations.{/quotes} And for these operations, they can pretty much charge what they want-the patients feel they have little choice and are not even told how much it costs until the bills arrive… and continue to arrive from each specialist, from the anesthesiologist, the pharmacy, the rehab facility, and any other service involved. Tony-not his real name, by the way-ended up paying about $800, including his bus ticket and hotel room, and had excellent treatment.

Health-related travel has been going on since our ancient ancestors journeyed to healing hot springs. Roman army generals sent their officers to the Dead Sea to recuperate in the mineral waters. In later times, so many Brits traveled to the hot springs of Germany and Switzerland that whole towns grew up to service the spas-still evident by their names Baden Baden, Wiesbaden, and about 200 other towns with bad ("bath") in their names. These towns demanded railways for better access, which then enabled the rapid industrialization of the continent.

Now, the same global economic shift is occurring as health care becomes increasingly outsourced. It started in Thailand in the 1990s. Along with Taiwan, Singapore and Korea, Thailand was one of the "Asian tigers" with booming economies. When the economic crash occurred, Thai hospitals suddenly found themselves without government funding. They turned to tourism, offering cosmetic surgery and other expensive procedures for about one-fifth the cost in the United States. India, Singapore and Malaysia followed suit. Now, "medical tourism," as it has come to be known, is one of the greatest growth industries in these countries. {quotes}Thailand even has a special line at customs to expedite visitors arriving for health care.{/quotes} India, meanwhile, is in the process of building dozens of billion-dollar specialty hospitals with state-of-the-art treatment for everything from hip replacements to heart transplants. While President Bush curtailed further research on stem cell therapy, you can get stem cell treatments in South Korea, Thailand, India and Singapore, which specialists at Harvard University estimate are about five years ahead of the most advanced care available in the United States.

Michael Moore's film "Sicko" showcases the failures of the American medical system in all its absurd, disgusting and frightening aspects. Less convincing, however, are the solutions he proposes. Canada, Cuba, France, and other countries may have better health care systems, but they are far from ideal. {quotes align=right}No one seems to have noticed that medical tourists in India and Thailand are as likely to come from Canada as from the United States. {/quotes}The fact is, health care is expensive. It is expensive in the same way that making shoes or writing computer software is expensive. Our shoe and computer companies have found an obvious solution-have the stuff made in other countries where they can pay workers a tiny fraction of American wages and cut all sorts of other costs as well.

While politicians come up with all sorts of schemes to try to solve the health care crisis-none of which, in my opinion, will do anything substantial to change the system-individuals and companies are quietly taking their business elsewhere. When Hawaiian crooner Don Ho wanted stem cell therapy for his heart condition, he went to Bangkok. Toyota has arrangements with a hospital in Chiang Mai, Thailand, for treatment of its employees. Even giant health maintenance organizations are starting to see that they can be profitable if they have their patients treated outside the country, and several in California are exploring arrangements with hospitals over the border in Mexico.

Medical tourism will not work for emergency procedures-if you have a heart attack, you are not going to fly to Thailand. Nor is it likely to have a big impact on primary care-you probably won't travel overseas to treat a headache. But the prospect of combining a vacation with health care makes even minor care very attractive. When I was in Honduras this spring, I took the opportunity of having some dental work done. The money I saved paid for a good part of the trip. If you want to get an "Executive Physical"-a thorough head to toe exam-it will set you back about $700 to $1,200 here, depending on what is included. In Phuket, Thailand, you can get an equal or better examination for as little as $50. Add a couple of veneers for your smile and your savings have paid for your Thai vacation.

{quotes}The great majority of the excessive cost of health care in the United States is not due to emergency or primary care. It is major surgeries such as hip replacements, which cost an average of $53,000. {/quotes}The most lucrative part of health care is cosmetic surgery. Stomach reduction typically costs $20,000 and up, to $70,000 or more. It is these procedures that drive the medical care system-and drive doctors into becoming specialists rather than primary care physicians.

What happens when patients go elsewhere? What happens to radiologists who earn an average of $350,000 per year when hospitals can have X-rays and MRIs read by a radiologist in India or the Philippines, as is now easily possible, for one-tenth the cost?

I believe that medical tourism will eventually have a profound impact on the current system. American doctors and hospitals will have to respond to foreign competition by offering service that is better, cheaper, and simply more attractive. And it won't happen by government legislation or some complex new health care scheme. It will happen by people voting with their pocketbooks.

Paul Gahlinger is an adjunct professor of medicine at the University of Utah, and the author of "Illegal Drugs: A Complete Guide to Their History, Chemistry, Use and Abuse" (Penguin 2004). He recently completed a book on medical tourism.

This article was originally published on July 30, 2007.