For Medical Tourists, Simple Math
nytimes.com
nytimes.com
A simple legal remedy here would be to invalidate this sort of NDA agreement. The government is already involved as a customer in the health care market, and having the courts simply no longer recognize contracts that prohibit disclosure of prices would bring some immediate transparency to many involved.
The law could also go a step further and actually set up/order public listings of prices (this is already done in a lot of industries where vendors try to avoid competing on price).
My ailment[1] prevented me from sleeping most nights, caused severe, productivity-ending headaches all day, and caused me to pop ibuprofens like candy. My PCP attempted to use water to eliminate what he believed was an earwax impaction 14 times on separate days. It had been almost 2 months of me completely disabled before he was willing to put in a referral to the ENT. When he did, they told me it would be six months. You can imagine my frustration.
So, I had a friend drive me to a clinic in Washington state. A bit of discussion, $900 and two visits later, I had seen an otolaryngologist, he had used a small curette to clean out the ear canal, and I was better. $900 to not cry myself to sleep all day for six months seemed like a pretty good deal to me.
Six months later I got a phone call from an office of an ENT here in Canada. I was unbelievably angry.
[1] I had a condition where the skin had grown over the eardrum in your ear. It required surgery by an otolaryngologist to remove the problem and restore my hearing.
Good thing I had travel insurance.
Ordinary tourists who come for other reasons and happen to seek medical care are a completely different story - they'll be charged the "highest possible fee, 'cause we can" rate.
So he scheduled surgery, it wasn't due for 4 years. His life wasn't in danger, it wasn't completely debilitating, he could walk with a limp. So rather than go to another country, he actually soldiered it (he's the soldiering type it seems). Well guess what 4 years of a persistent limp + exercise does to you. Nothing good. He finally had the bone chip removed, I'm sure a cheap operation. Only now he's had 6+ years of physiotherapy correcting his improperly developed muscular system.
+1 Canada for having a public health care system that moves fast when it needs to.
-1 Canada for having a public health care system that moves incredibly slow when it doesn't need to.
I had a similar experience with the UK's public healthcare system when I was studying abroad there; had I been completely dependent on it, I likely would've died before being treated.
My wife has gone to Russia twice for dental work (her home country). Was a fraction of the quotes here, including airfare.
What about liability?
Is this any good: http://www.treatmentabroad.com/medical-tourism/ratings-and-r...
Some objective information, like third-party-audited statistics on treatment outcomes, on the other hand, would be very valuable.
It could be much bigger, across more procedures... but often people needing care are, by virtue of both age and their current medical worries (and past experiences with bad providers), less adventurous.
A big breakthrough would be if Congress, as a cost-saving measure, allowed Medicare payments for out-of-country treatment.
If Congress cared about saving money when it comes to Medicare they wouldn't have passed Medicare Part D, which by design doesn't allow for the negotiation of lower drug prices with pharmaceutical companies like the Department of Vererans Affairs is allowed to do. The fact of the matter is that a lot of palms are getting greased in Washington when it comes to healthcare. Thus why Obamacare doesn't have a public option.
Pharma companies make a wildly disproportionate share of their global profits in the US simply because they don't have to negotiate with a large 'super-buyer" (e.g. medicare).
Now if pharma R&D were productive I wouldn't have a problem with this, but it's notoriously unproductive (and not just because of the admittedly overly burdensome FDA regulations).
I would support a grand compromise: 1) for pharma companies: reduce FDA hurdles for drug approval, but add more aggressive post-approval tracking (to reduce the risks associated with a lower regulatory hurdle) 2) for the rest of us: allow medicare to negotiate aggressively on price, this will have a ripple effect and lead to lower drug prices for all.
1. force drug makers to match the lowest price that it offers to anyone else. In other words Medicare gets the same (or lower) price as big insurers like United.
2. force drug manufacturers to discount the cost of drugs for Medicare Part-D once the patient enters the donut hole. Over the next 5 years that discount will increase to 50% of the cost incurred within the donut hole (this will total several billions per year)
3. for Medicaid, force the drug manufacturers to provide a 23.1% discount off the WAC (wholesale price) OR the lowest price offered to anyone else (whichever is lower)
4. for disproportionate share hospitals (hospitals that serve the uninsured), force drug companies to provide the Medicaid discount (at least 23.1%) to those hospitals for all the drugs they buy, whether or not they go to the uninsured
5. if the drug company increases the cost of its drug at a rate greater than the rate of inflation (CPI), they have to pay CPI penalties each year. There are some drugs that Medicaid gets a 90% discount on (far lower than any insurance company could get)
So yes, you are correct that federal gov't doesn't directly negotiate individual drug prices, but it sure as heck uses it bargaining power to get some super sweet deals!
They would never do it. The amount of fraud in Medicare is astounding because the gov't doesn't use a lot of resources to verify claims. Can you imagine what would happen if the services were provided outside of the US? You probably couldn't even sue the provider to recover money from fraudulent claims.
*Personally I got major Dental surgery by a top doctor in Peru for ~ $300
Another good place to start understanding the (dis)incentives in US healthcare pricing is Time magazine's "The Bitter Pill" http://www.time.com/time/magazine/article/0,9171,2136864,00..... Though it's important to note it's not just a US -> abroad market, it's a many-many graph. People travel for cost, procedure availability, doctor specialization, for the experience of travel, etc.
If anyone is interested in talking and passionate about this topic, I'd be happy to treat you to coffee with my co-founder and I in downtown SF. Feel free to email me, my email is in my HN profile.
Put simply, everyone wants "the best care" when they never have to actually pay for it. And as long as providers are incentivized to provide "the best care", they will do it, as lost as "best" equals "expensive".
And since we have such a high proportion of non-insured here, those admissions raise the cost for everyone else who DOES have insurance.
COBRA does not, unlike other federal statutes such as the Family and Medical Leave Act (FMLA), require the employer to pay for the cost of providing continuation coverage. Instead it allows employees and their dependents to maintain coverage at their own expense by paying the full cost of the premium the employer and the employee previously paid, plus up to a 2% administrative charge (50% for the latter 11 months under the disability extension).
It's better than individual coverage because individual plans are made more expensive to counteract adverse selection (i.e. people who buy plans are sicker than those who don't) but it's not really affordable for someone who just got laid off.
Just think every time a company negotiates prices both sides spend time which is why stores list prices and don't let you negotiate but car dealerships do.
So my theory is that there is no incentive to cut costs, everyone in the healthcare industry profits form the inflated costs. Even the insurers do as long as they can keep raising the insurance costs.
Your health is priceless. You'd pay anything for yourself or your children. Therefore the going rate will be whatever maximizes profits, which doesn't necessarily mean providing services to everyone (at least in backwards countries) but usually means providing service to "most of the community", more or less.
That's why when very few people are tourists, its profitable for the tourists. Obviously this doesn't scale because if you can outsource basically all non-emergency medical care, prices will rise for tourism because the served group now earns 5x as much so "why not" charge 5x as much if the locals don't go there anymore.
Its no different than "tourist-y" restaurants and stores. Once the locals are chased away, prices explode to what the tourists can pay, what the locals pay doesn't matter, they're kicked out of the market.
Once the real economic value disappears, all thats left are scammers. So "everybody knows" that going to .mx for raw vanilla, tequila, and jewelry is a losing proposition because so many crooks are involved. You'll hear accusations of this for medical tourism, but its just not there yet. It'll take awhile but the economic forces are inevitable, at which point there will be true medical disaster stories about scammers.
> “Imagine you’re the C.E.O. of Zimmer,” he said. “Why charge $1,000 for the implant in the U.S. when you can charge $14,000? How would you answer to your shareholders?” Expecting device makers “to do otherwise is like asking, ‘Couldn’t Apple just charge $50 for an iPhone?’ because that’s what it costs to make them.”
> But do Americans want medical devices priced like smartphones? “That,” Dr. Cram said, “is a different question.”
Indeed.
Maybe mixing something that is designed to work better when no ethics is involved (free market and capitalist ideology) with a highly relative to ethics sector (healthCARE) isn't such a good idea. Well, not for shareholders of course.
* The hospital system in Belgium is 99% either state or non-profit owned. Less sticky fingers. Less luxury.
* Infrastructure (buildings, tools, ...). The infrastructure is extremely heavily state subsidised.
* Medical professional wage negotiations. Medical professionals earn quite a bit less in Belgium than in the US. Quite many (most?) medical pros actually seem to have their priorities right: helping people solve medical problems.
* Choice. In Belgium, people, not insurers choose the hospital they go to, based on reputation and perceived quality.
* Volume. Healthcare in Belgium is fairly accessible, probably one of the most accessible in the world. This means few people putting off operations for financial reasons, so higher volume.
* State subsidies spilling over to foreign patients in unintended ways. I could very well imagine some of the marginal cost of an operation on a non-resident American citizen also being carried by the state in other ways.
Two anecdotes, logical consequences of this system.
1) My (poor by US standards) 90 years old neighbour had a hip replacement at the age of 86, 100% paid by the state.
2) An aunt working as a nurse told me about a phenomenon that was quite common until a few years ago: "winter rabbits", old people "dumped" into hospital for several weeks even if they were not ill. Relatives dumped them at the hospital as a (to them) low cost way of getting rid of them for a few weeks while on holiday for example.
For instance, it is acknowledged in international comparisons as really hard to get diagnosed because doctors just don't have the time, largely because of administration. Me and others I know have had years and decades of lowered life quality from easily cured problems like bacteria infections, simple knee problems, allergies and iron/vitamin deficiencies.
I've heard good things about the German health care system.
Notes: I have also lived a few years outside of the Nordic countries, so I have some perspective. And I agree that the US system seems the craziest one on the Western world.
Edit: The government has recently decided that all illegal immigrants in Sweden will get free health care, without any paperwork. If you need an expensive and can fake an Ukrainian accent in English, or something similar, there is a cheap solution for millions of Americans with a ticket to Sweden...
If the vast majority of people treated are not subject to itemised accounting, the bureaucratic expense of having itemised accounting for one small group can actually be higher than just treating them for free as well.
Since it seems I need to explain in more details:
The problem is that potentially anyone which can get to Sweden can get expensive treatment free. This is potentially ruinous for a small country. Just the millions of poor gypsies in Romania/Bulgaria which lack good health care for poor people ("I'm from the republic of Moldova outside the EU. I am here illegally because criminals are after me") is enough to break the Swedish health care system if they use this loophole in an organized way. Or normal citizens in those countries, for that matter. We will see...
Everyone benefits? Well, higher costs are obviously better for hospitals and doctors, but don't insurers want to control costs? Not really. As long as insurers pass costs through, the more they pay, the more they can get away with charging, and the bigger their profits can be. Insurers want predictable and rising costs, not low ones.
How egregious is the inflation getting? Let me give you an example. From the mid-90s to now the cost of childbirth tripled. See http://www.nytimes.com/2013/07/01/health/american-way-of-bir... for confirmation. In England there was controversy because the royal childbirth cost over 2x what the average childbirth there does. It still cost half the average US childbirth.
And no, Obama's plan does not address this issue. It says that insurance companies must spend at least 80% of premiums on health care. If I was an insurer, I'd look at this and see fraud as an opportunity to have the 20% slice which covers my costs and profits continue to rise, and put out effort to catch exactly enough fraud to keep the amount paid out at exactly 80% of the premiums that I collected.
The directive created a legal framework for patient’s right to seek healthcare in another member state and for reimbursement.
http://eur-lex.europa.eu/LexUriServ/LexUriServ.do?uri=OJ:L:2...
The ability to sue for millions of dollars is the one "advantage" of buying your medical care (or airplane tickets) in the US. We each need to decide how important that is to us.
That isn't necessarily true, as some states have caps on tort damages, and more corperations are lobying for similar caps/limits on civil restitution via state law: http://www.nytimes.com/2013/01/25/us/even-with-counsel-texas...
But that's a reason to choose Belgium over somewhere like Guatemala -- while you won't get the gift shop or valet parking, the quality of care is much more likely to be at the same level as in the US.