Outsourcing health: Some employers, insurers send Americans abroad for surgery

By Malcolm Foster And Margie Mason , Associated Press

She's a rodeo barrel-racing champion who runs a 180-acre ranch in Oklahoma when she's not bouncing across back roads selling farms. Dodie Gilmore is a spry 60-year-old who loves the outdoors, but when she could no longer straddle her faithful horse, River, she knew it was time for a new hip.

But how could she afford it? As an independent contractor for a small Coldwell Banker real estate franchise in Durant, Okla., she knew her privately purchased health plan would never pay up to $40,000 for the operation.

So she asked her boss about traveling to India where hip resurfacing would cost just $7,000. He not only gave his blessing, but offered to foot the bill, minus travel and hotels - making Gilmore one of the very first Americans sent overseas for surgery by an employer.

"The doctors were wonderful," Gilmore said days after being discharged, sipping coffee at a New Delhi, India cafe with her sister, Carol, who accompanied her. "The overall care was pretty darn good."

With an estimated 45 million uninsured Americans, some 500,000 trekked overseas last year for medical treatment, according to the National Coalition on Health Care. Asian hospitals in Thailand, India and Singapore have long been swarmed by medical tourists looking for tummy tucks and face lifts, but many glitzy, marble-floored facilities are now gaining reputations for big-ticket procedures, including heart surgery, knee and back operations.

More and more patients like Gilmore are returning home and spreading the word about an alternative to America's ailing health system. Businesses, insurance companies and even a state lawmaker are now also starting to eye the potential savings of outsourcing health from the world's richest country to the developing world.

"It's just one of the many ways in which our world is flattening," said Arnold Milstein, chief physician at New York-based Mercer Health & Benefits, who's researching the feasibility of outsourcing medical care for three Fortune 500 corporations. "Many companies see it as a natural extension of the competition they've faced in other aspects of their business."

Some American hospitals already rely on places like India for X-ray readings and other diagnostics, while also importing foreign doctors and nurses. But the U.S. health care industry has been largely immune to overseas competition - just one reason behind soaring costs.

Premiums for employer-sponsored health coverage have surged 87 percent over the past six years, according to the Kaiser Family Foundation, putting a huge burden on both companies and employees. Family health coverage now runs about $11,500 annually, with workers themselves forking out nearly $3,000.

Companies, workers eye pros and cons

But just as shipping U.S. manufacturing to China and call centers to India initially created loud opposition, some critics are already preparing to fight any possible mass exodus of Americans packing their bags to go under the knife overseas.

In September, Canton, N.C.-based Blue Ridge Paper Products Inc. was set to send one of its employees to India for a gall bladder operation. Carl Garrett would have been the first U.S. employee sent abroad for medical care through an employer-sponsored pilot program, which would have allowed him to share the company's savings.

Shortly before Garrett was to leave, the United Steelworkers, America's largest union, pulled the plug.

"We don't want to expose our members to the risks associated with providing health care in the Third World," said Stan Johnson, a union spokesman. "This is perceived to be voluntary, but voluntary programs tend to lead to mandatory programs."

Blue Ridge ultimately scrapped its plan for union members, but several other U.S. businesses and insurance companies are starting to explore the option of exporting patients.

United Group Programs, a Boca Raton, Fla.-based company that sells self-insurance policies to small businesses, is offering a plan that sends patients to Bumrungrad International Hospital in Bangkok, Thailand, which drew 400,000 foreigners last year - including 55,000 Americans. UGP says the plan will save employers more than 50 percent on major medical costs and slash employees' out-of-pocket expenses to zero.

Blue Shield of California and Health Net of California both offer lower-cost policies allowing members to seek medical care in Mexico. Blue Cross Blue Shield of South Carolina is seriously looking at an overseas component for its health plan's 1.5 million members.

In addition, West Virginia lawmaker Ray Canterbury plans to propose legislation next year that would give government employees the option of traveling abroad for necessary procedures, which could save the state up to $2 million annually. He wants to offer incentives, including extra sick leave and 20 percent of the cash saved by going abroad - allowing workers to actually make money on the deal.

Weighting the risks overseas

But even with the growing momentum, big questions must be asked by anyone considering treatment abroad.

Despite the five-star facades of some hospitals - fountains, white marble floors, even a Starbucks and McDonald's inside Bumrungrad's lobby - the comfort of having a major surgery near home with family at the bedside is a far cry from the experience in the developing world, where culture shock alone can be stressful.

Pollution, poverty and insane traffic are all part of the experience when visiting hospitals like the Indian-owned Max Healthcare facilities in New Delhi, where it's not uncommon to see people urinating along roadsides. Jet lag, traveler's diarrhea and strange foods can couple with the unpredictable, such as September's bloodless military coup in Thailand.

Language and cultural barriers also can make communication with doctors and nurses frustrating for some Americans, who are used to peppering their physicians with tough questions and expecting straightforward answers.

Some Asian cultures rely on hints and subtleties to communicate, and doctors in some countries are regarded as authority figures who often aren't questioned. Follow-up care back in the U.S. also can be an issue.

"There are a lot of risks," said Rick Wade, a senior vice president at the American Hospital Association. "What happens if something goes wrong?"

In February, Joshua Goldberg, a 23-year-old American traveling in Thailand, died at Bumrungrad after seeking care for a leg injury. His father, James Goldberg, has set up a Web site alleging the hospital administered a deadly drug cocktail to a patient with a history of substance abuse.

Bumrungrad insists the care given was appropriate. Thai authorities are investigating, which is standard with all unexpected hospital deaths.

"What I'm dedicated to doing is to try to alert people to at least do their homework and consider very carefully what they're getting into. Why is this such a good deal?" Goldberg said. "You might not walk away. That's what happened to my son."

It's ultimately up to patients themselves to investigate hospitals and physicians before considering surgery abroad. The Internet is loaded with resources that range from doctor bios to patient blogs.

Countries recruiting American patients

As the phenomenon grows, more countries are trying to get in on the action. Packages offering city tours, day spas and even golf have been combined with health checkups and cosmetic surgery.

Some experts predict greater access to options like these will eventually drive more people to take control of their own health care.

About 100 foreign hospitals have been approved by the international arm of the Chicago-based Joint Commission on Accreditation of Healthcare Organizations, which also accredits American hospitals. And many doctors working in overseas facilities catering to medical tourists are trained in other countries, often in the U.S. or Europe.

The Max Super Speciality Hospital where Gilmore had her surgery is working to become accredited, but she said she felt comfortable from the very beginning. Even if her boss had refused to pay for the surgery, she likely would have made the trip on her own because her insurance wouldn't pay to fix her pre-existing condition.

"It's either that, or do it in the States for $28,000 to $40,000," she said. "The risk of it didn't really weigh on me."

In addition to saving thousands - the three-week trip totaled about $12,000, including the surgery, travel and lodging for two and a tour of the Taj Mahal - she also underwent a new technique just approved this year in the U.S.

Instead of total hip replacement, which limits mobility and requires the top of the femur to be cut off and a long shaft inserted, hip resurfacing uses only a small ball-and-socket device that enables patients to maintain their flexibility.

Gilmore's Indian physician, Dr. S.K.S. Marya, chief surgeon at the Max Institute of Orthopedics & Joint Replacement, has performed 150 hip resurfacing operations over the past two years. He sees about one American a week.

"Every day I feel better," said Gilmore, who plans to be back in the saddle within six months. "I don't have near the pain."

AP Business Writer Malcolm Foster reported from Bangkok, and AP Medical Writer Margie Mason reported from New Delhi. AP writers Tom Breen in Charleston, W.Va., and Teresa Cerojano in Manila contributed to this report.

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