
My adventures in medical tourism - solutionyogi
https://www.chrisstucchio.com/blog/2015/medical_tourism.html
======
clamprecht
I should mention that Paul Buchheit wants to fund the Uber of medical tourism:

[https://twitter.com/paultoo/status/566379518261088258](https://twitter.com/paultoo/status/566379518261088258)

The tweet: "I want to fund the 'Uber' of medical tourism Needs 5 star service,
simplicity and safety Let me know if you apply -
[http://www.ycombinator.com/apply/"](http://www.ycombinator.com/apply/")

It really has to happen. Health care in the US is just fucked, and everyone
knows it.

~~~
jasonlotito
> Health care in the US is just fucked, and everyone knows it.

And yet people still move here for the "fucked" health care because it's
cheaper, better, and available unlike other countries held in high regard,
such as Canada. I am one such person who was lucky enough to be able to do
that, and would never return to Canada after the abusive treatment handed out
by the health care "professionals."

~~~
ashark
So I suppose there's a serious movement to reform their healthcare system to
be more like ours? Maybe also in all the other universal healthcare-having
countries with advanced economies (so, the entire rest of the OECD states,
more or less)?

~~~
jasonlotito
There is a push to reform the way they handle long term care in Canada, but
it's not something people think about until it happens to them. Mental health
care is generally like that. Do some reading on the lack of autistic services
up in Canada and the efforts people are trying to go through to improve the
lack of support up there. The services are severely lacking.

I had to deal with it in 2010-11, and it's only gotten worse from people we
talk to still dealing with it. Don't blindly think that just because you can
get your broken arm fixed for cheap or no cost that it means health care is a
solved problem in other countries. Coming to the US, it was 100% cheaper,
available now, and better compared to anything Canada remotely offered, even
looking at private services.

~~~
ashark
Is it a problem that's more pronounced in some provinces than others? My
understanding was that there's a nationwide mandate to provide universal
insurance, but that the details are left to the provinces.

As for mental healthcare in particular: thanks for the insight, I know very
little about how that works in other countries. Seems like an area with room
for improvement just about everywhere, unfortunately. I'll definitely keep
that kind of thing in mind when reading on related topics in the future.

------
solutionyogi
I am originally from India and came to the US 10 years ago. I still can't
believe that you can not call up a doctor/clinic/hospital in US and get a
price quote for something routine.

Chris's experience is representative of what one can expect from the Indian
health care system. If you are a working, middle class person, the free market
health care works extremely well.

~~~
itg
Part of the problem is you can thank the stranglehold the AMA has around the
US healthcare system to keep the number of doctors artificially low so their
salaries remain ridiculously high.

Here's another example: [https://www.washingtonpost.com/business/economy/new-
machine-...](https://www.washingtonpost.com/business/economy/new-machine-
could-one-day-replace-
anesthesiologists/2015/05/11/92e8a42c-f424-11e4-b2f3-af5479e6bbdd_story.html)

"Anesthesiologists tried to stop Sedasys.

They lobbied against it for years, arguing no machine could possibly replicate
their skills or handle an emergency if something went wrong. Putting someone
to sleep is an art, they said. Too little sedation, and the patient feels
pain. Too much, and the patient dies. Anesthesiology requires four years of
training after medical school, meaning careers might not launch until the
doctors are in their 30s. It’s one reason the profession’s median salary is
$277,000 a year, according to research firm Payscale."

~~~
chimeracoder
> Part of the problem is you can thank the stranglehold the AMA has around the
> US healthcare system to keep the number of doctors artificially low so their
> salaries remain ridiculously high.

The AMA is a common scapegoat, except that the AMA has literally nothing to do
with the number of of doctors supply-side.

You're probably thinking of the AAMC, which has nothing to do with the AMA,
and is responsible for the number of medical students who graduate each year
from the US. Except the AAMC has very deliberately and openly increased the
number of medical student slots each year for over a decade, specifically with
this goal in mind.

But even this is a moot point, because the number of people gradating with MDs
is not the bottleneck - the problem is that doctors can't practice medicine
until they complete a residency program. We graduate more medical students
every year than we have residency slots available, so increasing the number of
graduates even further will have no effect.

Increasing the number of _residency_ slots is up to Medicare, because Medicare
funds residency programs nationwide.

~~~
vonmoltke
> Increasing the number of residency slots is up to Medicare, because Medicare
> funds residency programs nationwide.

No, it isn't. Congress limited the number of residency slots Medicare could
underwrite, but medical residency is not controlled by Medicare. Additionally,
Medicare only pays for about 25% to the total costs incurred by residency
programs.

In fact, the law that created Medicare specifically stated it was to subsidize
residencies “until the community undertakes to bear such education costs in
some other way.” Understandably, no one has stepped up to replace the federal
government gravy train. Since the AAMC is predominantly responsible for
Graduate Medical Education (the formal name of residency) it is absolutely the
appropriate scapegoat for the residency bottleneck (since their only answer is
to make the FGGT bigger), as is the AMA for pushing increasingly long
residency requirements for medical licensure.

~~~
chimeracoder
> The law that created Medicare specifically stated it was to subsidize
> residencies “until the community undertakes to bear such education costs in
> some other way.” Understandably, no one has stepped up to replace the
> federal government gravy train.

It seems like you don't want Medicare to be responsible for the funding of
residency programs, and you'll get no disagreement from me on that point. In
an ideal world, this would not come Medicare, because Medicare is the least
efficient funding source for - well, pretty much anything.

But the fact remains that residency programs are not a profit center for
hospitals, and hospitals cannot absorb an extra $9.8 billion/year just to
train residents. And there's no other funding source for these programs at
most hospitals that doesn't ultimately make its way back to the patient in
some form.

It's also worth mentioning that the Balanced Budget Act capped Medicare's
funding for residency programs specifically to _reduce_ the number of
residency slots available and avoid an "oversupply" of doctors. It's not that
the AAMC is looking for free money so that they can keep the number of
physicians artificially low, as you're implying; the external funding is what
drove the increase in the number of physicians in the first place.

If you want residency programs to be funded by someone other than Medicare,
that's fine, but just realize that the free-market would reach equilibrium at
even _fewer_ residency slots than we have today.

------
JamesBarney
It's true that healthcare is terrible in the U.S. if you don't have health
insurance, but he overstates his case. Chris compares a 1 in a 1000 nightmare
scenario to his very average experience.

A $112,000 error happens in the U.S. but is rare. Typically the type of
surgery he mentions costs between $20,000-$50,000. Or 50-100% of a the U.S.
gdp per capita. This is smaller than in India where the cost of his surgery
was 130% of the Indian gdp per capita.

And the issues with rounding errors has to do with the large amount of health
insurance in the U.S. not necessarily free market vs. regulation. When the
majority of consumption in a market is driven by enterprise customers, the
pricing can become strange and very unfriendly to individuals.

[0][https://pricinghealthcare.com/prices/IowaCityASC/spine-
back](https://pricinghealthcare.com/prices/IowaCityASC/spine-back)
[1][http://www.backsurgerycost.com/how-much-does-a-discectomy-
co...](http://www.backsurgerycost.com/how-much-does-a-discectomy-cost/)

~~~
akg_67
As a patient, US healthcare is terrible even if you have health insurance.
Patient is at the bottom of totem pole in US healthcare, and just a number for
doctors, hospitals and insurance companies and everyone else involved in the
system.

Just a couple of anecdotal personal recent experiences with US healthcare.

1\. Recently I witnessed the trouble my primary care physician (PCP) had to go
through with insurance company to get approval to perform CT scan. I couldn't
believe the 30 minutes, my PCP had to spend on the phone with the United
Healthcare person. This is the doctor spending time on the phone explaining
all the medical reasons for recommending CT scan and not some administrative
person in doctor's office.

This is in contrast to a friend's experience whose PCP kept prescribing pain
killers and other prescriptions instead of pushing insurance company for
further tests for abdominal pain. The friend later was diagnosed with stage 4
cancer when showed up at ER with same symptoms.

2\. While researching a local major hospital rated highly for quality of
surgery, I came across the reports of quite a few cancer patients complaining
about hospital quickly discharging patients after major surgery and
restricting pain medication while in hospital. The claims don't make sense as
hospital is rated so highly for Quality of Surgery and might be considered
anecdotal. Until I found that two of the measuring criteria for Quality of
Surgery was how long a patient stayed in hospital after surgery and dosage and
duration of pain medication administered after the surgery. Talk about
incentive misalignment. There is all the incentive for surgeon and hospital
administration to discharge you quickly to maintain and improve Quality of
Surgery rating.

~~~
Fomite
Have you considered that discharging patients to their home, and moderating
their pain medication, may actually be signs of quality care? "The patient
gets what they want" is not the only sign of quality.

~~~
akg_67
I would like to hear more about how discharging patient early and moderating
pain medication is a sign of quality care?

The author of original article mentioned staying in Indian hospital for 4
nights. Do you think a US hospital will keep you 4 nights for same surgery? I
seriously doubt it. You most probably will be released few hours after the
surgery or at most after overnight stay. Is the quality of care becomes lower
because an Indian hospital kept a patient for 4 days instead of 1 day by US
hospital? What does it say about relationship between quality of surgery and
all these metrics such as duration of hospital stay, pain medication dosage
and duration?

I found a lot of studies which used hospital stay duration and pain medication
dosage and duration while in hospital as a proxy to quality of surgery but
none that showed these metrics have anything to do with quality of surgery.
Also, while quality of surgery takes into consideration the pain medication
dosage and duration in the hospital, it ignores the pain medication dosage and
duration patient was prescribed after being released from hospital. Similarly
the overall healing and recovery time required by patient after the surgery is
ignored in favor of the portion of recovery time patient spent in hospital.
Hopefully, you see the incentive misalignment and mis-measurements.

You will get what you measure, nothing more nothing less. It is up to you to
decide whether a measurement is relevant or not to what you trying to measure.
You should not only worry about what a statistical study show but also what
the study doesn't show.

~~~
northern_lights
You can argue all you want about whether it's a good metric for surgery
quality or not, but if you're being discharged soon after surgery, the idea is
that your surgery went well enough that you don't need to be around $50mil
worth of life-saving equipment 24/7\. It has a valid place in the system, with
pros and cons like any other metric.

Hospitals are full of all kinds of hard-to-kill microorganisms. They really
are not good places to stay after a major traumatic event (e.g. surgery) if
you don't need the resources of the system; staying will only increase your
chances of getting a life-threatening infection. When I get home from the
hospital, I try to change out of my clothes as soon as possible for this very
reason.

As for pain medication, well...one only needs to look at the enormous rise of
opioid addiction and prescription medicine abuse in the USA to see that
moderation of these very dangerous medications is in the patient's best
interest.

The medical system is _far_ from perfect, but don't operate on the assumption
that the people working in the field are ignorant of the problems you're
pointing out. There are many things we could be doing better, especially on
the transparency and patient education side of things, but it's a huge
industry and big ships turn slowly.

~~~
Omniusaspirer
Patient education is the only issue here, but most of the public has no desire
to know anything about their care. They want a magic pill they can pop which
will make it all better and they want to sit in a hospital as long as they
feel like. This is because they aren't cognizant of the cost associated with
them sitting around like a fool soaking up thousands of dollars in resources
per day when they could be sitting at home healing instead.

One of the biggest flaws with the American health care system and single payer
as well is that it's removed the cost component from peoples considerations of
what care they should receive. We all pay for this idiocy in the form of our
skyrocketing insurance premiums. Do you really think people would want to sit
in a hospital if they actually had to pay the nursing staff $1000 per day out
of pocket? If they had to pay the janitor $20 for coming into the room to
clean up the mess they'd made? $200 for the physician followup? Of course not.

The above poster complaining about withholding opiates and statistically
backed discharge time frames is a huge part of what's wrong with health care
across the developed world- not just the US.

------
jkot
My wife had some complications after pregnancy. UK and Ireland has GP referral
system, where single doctor coordinates all specialists. In theory it is good
system. But our GP ignored basic symptoms and pushed bullshit like
"depression" or "have you tried acupuncture?". We paid each GP visit, even for
saying hi and collecting results, it was obvious GP was just pushing for more
visits.

This was going on for several months.. Eventually we visited doctor in Athens,
the whole thing was diagnosed and solved in weeks. Solution was $2 pill and
routine surgery.

I really recommend to anyone with some 'mysterious' health issues to visit
REAL doctors.

~~~
lifty
This is similar to how the Dutch system works. You normally go to your GP
which will refer you to a specialist if required. The problem is that they
always want to try a simple treatment first, without investigating thoroughly
the causes of the illness. That means that you get sent home with paracetamol
and only if you go the 2nd or 3rd time to the GP will you get sent to the
specialist. My friend developed a type of auto-immune disease and because of
the delays made by his GP his condition worsened a lot.

Since a lot of people have hypochondriac tendencies, this system has the
advantage of reducing the amount of people that go to hospitals, which in turn
reduces both infections in hospitals and the overall costs of the system. But
for individuals, the chances of getting screwed are higher.

edit: typo

~~~
throwaway7767
This bugs me a lot, as I don't seek medical attention unless I damn well need
it. The GPs will just tell you to take it easy, eat some paracetamol and come
back in 2-3 weeks if it's still an issue.

I understand the desire to not spend resources on hypochondriacs, but the last
time I heard that from my doctor I ended up being admitted to the intensive
care unit at the hospital the next day with meningitis. According to the
doctors there, I could have died if I'd waited a bit longer.

Needless to say, I don't feel as confident in our healtcare system after that.

~~~
lifty
Yes, I've heard similar stories from various people. I guess you have to be
very insistent and convincing to your GP when you feel ill, or else you risk
delaying a proper diagnostic.

On the bright side, the Dutch hospitals have a great track record at low
multi-resistant bacteria, which are more common in other countries. One of the
reasons for this might be their stricter rules of admitting people in the
hospitals.

------
Dove
Cash friendly places are getting more prevalent in the US, but you have to
look for them. For example, one of the hospitals in my area publishes this
(very sane) price list: [http://swedishhospital.com/patient-
financial/?page_name=pric...](http://swedishhospital.com/patient-
financial/?page_name=pricing) I go to them. :)

There are urgent care centers that are the less-crazy version of ERs, and a
lot of primary care stuff can be done self pay. While I have access to
insurance through my work, I vastly prefer the quality of the self pay system.
You do need to do some research in advance, but there are some pretty cool
innovations out there, and services you just can't get via the insurance
system.

[http://theselfpaypatient.com/](http://theselfpaypatient.com/) is a good
resource.

~~~
chiph
Be careful when picking an urgent-care center. Some are now for-profit
emergency rooms. They can treat a much broader set of maladies & injuries than
an urgent-care, but they're priced accordingly.

[http://www.kvue.com/story/news/investigations/defenders/2015...](http://www.kvue.com/story/news/investigations/defenders/2015/11/16/buyer-
beware/75871654/)

------
hvmonk
My understanding is doctors in US are trained to scare you about every
possible negative outcomes. I find visiting a doctor here is much much more
stressful than doing it in India.

For a simple chest pain, doctors here would tell you 145566 possible scenarios
that may happen with your body, and wouldn't confirm any unless he sees a lab
test. And then, a tide of lab tests would start, which will cripple you
financially, and emotionally because all you are thinking is which test would
be +ve, which -ve; diving on internet where people usually blog about their
-ve experiences. Usually, it could be just a muscular pain, etc, which become
so irrelevant as you are undergoing all these lab exams.

I don't want to blame the doctors here as such, because that's how they are
trained here. I guess it boils down to this robust "suing infrastructure"
here, that if you missed out a rare symptom with a patient, he will sue you
and finish your career.

One thing which I couldn't understand is why in a developed country, lab tests
are so expensive. An Xray, costs about $100; similar thing costs about Rs 80
(equivalent to $1.25). Shouldn't they be cheaper here, given there are gizmos
for everything, and all electronics items are much cheaper here than India. I
think these costs are all artificial.

I think a mix of both approaches (insurance + free market) would better.

~~~
chimeracoder
> One thing which I couldn't understand is why in a developed country, lab
> tests are so expensive. An Xray, costs about $100; similar thing costs about
> Rs 80 (equivalent to $1.25).

Many lab tests - though not all - are effectively commoditized. There is
little difference in quality, and the requisite supplies are widely available
at low costs. X-rays have been used for medical purposes for literally over
100 years, and it's not very difficult to train someone to take an x-ray
properly using modern equipment. (Actually _interpreting_ the results of a
test is a different matter).

For tests which fall under these categories, it will always be more expensive
to obtain them in the US than in India, because the cost-of-living in the US
is much higher, and paying people to actually perform the tests dominates the
costs of the test itself.

There's a little more to it than that, but that's the general idea.

------
cryoshon
Yep. Medical tourism exists when the cost of local healthcare is inflated by
profit-seeking to flatly unaffordable levels, resulting in grotesque health
outcomes and extreme behaviors such as traveling thousands of miles or
committing crimes in order to end up in prison for care. I would like to coin
a term for this kind of disturbing extreme behavior incentivized by extreme
distortion of society: fever spasms. It sounds better in German, so:
fieberkrämpfe.

Out of pocket price of standard blood panel lab in the USA with a follow up
phone call if something is wrong, with insurance: $1500. There is no ability
to estimate even vaguely what the price will be beforehand, and the bill may
take a month to arrive in the mail. Your insurance agency will fight you at
every turn for all but the most mundane routine procedures. There will be a
billing error somewhere, and it will be to your detriment. They may refer you
to collections if you do not pay the incorrect amount while disputing the
charges, as happened to my girlfriend. Face time with the doctor is probably
minimal, and you will be stressed by the doctor's attempts to hurry you out
the door and probably forget to ask important questions.

Out of pocket price of extended blood panel lab plus two hours of doctor face
to face analysis without insurance in Argentina: $50 USD, and the doctor will
speak perfect English. Smartly, the doctor arranges the items on the blood
panel before you visit him in the first place. No in-depth discussion of your
health can begin before the doctor cannily takes your medical history via a
very casual schmooze-sesh which plays out more like old friends catching up.
You leave the office relaxed, understanding your health action-items.

Where do you think I'm going to go when I need serious treatment? The US
medical system is a failure and an international joke.

~~~
ashark
> There will be a billing error somewhere, and it will be to your detriment.
> They may refer you to collections if you do not pay the incorrect amount
> while disputing the charges, as happened to my girlfriend.

Yep. Can confirm: US hospitals and other care providers are total d-bags when
it comes to billing. It doesn't help that for anything remotely complicated
you end up receiving 2-3 _different_ bills from each of 5-6 different entities
(the hospital, a couple of doctors or departments in the hospital, a couple of
labs, a GP for your checkups afterward, _et c._ ), only one of which from each
will actually be the one you need to pay. It can easily take most of a year to
sort all the crap out, especially if you have any kind of dispute with
insurance or billing error from the providers (the bigger the procedure, the
closer the probability of this approaches 100%). Makes for a _totally_ stress-
free recovery. _eye roll_

It's like it's designed to screw up people's credit, even when they're
_trying_ to pay what they owe.

~~~
smileysteve
\+ 1

> It's like it's designed to screw up people's credit, even when they're
> trying to pay what they owe.

I had a bill that was 100% covered by insurance, only they never sent it to
me. it's 3 years later and despite my insurance now paying the bill twice,
countless conversations, some collections agency is still giving me calls, and
it's still on my credit report.

I have insurance, I make a great income, I paid every bill that I received.
Somehow it's still biting me.

(It's not a huge debt, and I disputed it as soon as the collection notice
arrived, and my credit is not direly affected)

------
SimpleXYZ
Socialized medicine or a pure capitalistic system would both be preferable to
the current system in the US. Right now it's the worst of both worlds.

~~~
arethuza
Even here in the UK - where we do have a socialist health care system there is
still the option of going private. The only option you don't get if you are a
normal tax payer is opting out of _paying_ for the state funded healthcare -
which is fine as far as I am concerned.

~~~
laurencerowe
The US spends almost exactly the same proportion of GDP on public healthcare
as the UK (~7.3%) but because the system is so horribly wasteful it gets much
less for its money. (Much of healthcare spending is on the old who are covered
by public Medicare because private insurance would be unaffordable.)

UK: 8.8% of GDP total spending, of which 83.3% public = 7.33%.
[http://www.ons.gov.uk/ons/rel/psa/expenditure-on-
healthcare-...](http://www.ons.gov.uk/ons/rel/psa/expenditure-on-healthcare-
in-the-uk/2013/sty-expenditure-on-healthcare--2013.html)

US: 15.2% of GDP total spending of which 48% ($3,426/$7,146 per capita) public
= 7.28%
[https://en.wikipedia.org/wiki/Health_care_in_the_United_Stat...](https://en.wikipedia.org/wiki/Health_care_in_the_United_States)

Edit: The 2014 figures are even worse. 17.5% of GDP total spending of which
28% federal and 17% state and local = 7.88% of GDP public expenditure.
[https://www.cms.gov/research-statistics-data-and-
systems/sta...](https://www.cms.gov/research-statistics-data-and-
systems/statistics-trends-and-reports/nationalhealthexpenddata/nhe-fact-
sheet.html)

~~~
yummyfajitas
India: 4%.

[http://data.worldbank.org/indicator/SH.XPD.TOTL.ZS](http://data.worldbank.org/indicator/SH.XPD.TOTL.ZS)

~~~
arethuza
Not sure what that is supposed to demonstrate - it's hardly comparing like
with like to compare the UK with the "free at the point of delivery" NHS
available to everyone with a system where:

"This has led many households to incur Catastrophic Health Expenditure (CHE)
which can be defined as health expenditure that threats a household's capacity
to maintain a basic standard of living.[2] As per a study, over 35% of poor
Indian households incur CHE which reflects the detrimental state in which
Indian health care system is at the moment"

[https://en.wikipedia.org/wiki/Healthcare_in_India](https://en.wikipedia.org/wiki/Healthcare_in_India)

In fact, if anything, that perhaps reminds me of the pre-NHS UK healthcare
system - which Aneurin Bevan, the founder of the NHS, clearly referenced in
the title of his book _" In Place of Fear"_.

[https://en.wikipedia.org/wiki/Aneurin_Bevan](https://en.wikipedia.org/wiki/Aneurin_Bevan)

Also interesting to note that, according to that first Wikipedia article,
India appears to be considering a universal health care system.

------
BryantD
I'd recommend doing some more reading on the health care system in India. I
believe that it worked really well for the poster; my initial research seems
to indicate that there's a huge difference between the health care you can get
in urban areas of India and the health care you can get if you're poor and
rural. It's easy to build a health care system that works for people with
money.

The infant mortality rate in India was 38 per 1,000 in 2015. That's really not
good.

~~~
train_robber
My home state of Kerala has one of the best health care systems in India.

Infant mortality in Kerala is 6.7 (6.2 in US), life expectancy at birth is 76
(78.7 in US).

Per-capita income in Kerala is $2,271 ($53,000 in US)

So yes, you can provide good healthcare even with not a lot of money floating
around.

References:
[https://en.wikipedia.org/wiki/Kerala_model](https://en.wikipedia.org/wiki/Kerala_model)

~~~
BryantD
That's great reading and I appreciate it! From the Wikipedia article, it
sounds like the Kerala government is very involved in health care. Am I
reading that right?

~~~
train_robber
Yes the government is very involved. My mother worked as a nurse in the state
government health service and from what I have personally seen; the quality of
government care is good and very cheap (sometimes free). But its not just the
government; there are a lot of private institutions too in the state that
provide quality healthcare.

------
grecy
My brother broke his leg horribly in Australia when he was 17. It was the
worst break they'd ever seen at the hospital.

Ambulance ride, first surgery. Helicopter ride, second surgery, a month in
hospital and third surgery and then another month or so in hospital to ween
him off the morphine he had become addicted to, and to get walking again.

Of course, there was never a bill.

~~~
NeutronBoy
Similar when I got kidney stones here (Aus). Emergency dept, 3 night stay,
drugs, multiple x-rays, CT scan, 3 followup CT scans over 3 months, etc. No
bill in sight. I realise that I pay for it through my taxes, but I'm ok with
knowing if something happens I don't have to cough up thousands of dollars.

~~~
grecy
I happen to be in the US right now, and last night had a Christmas dinner with
people going elsewhere tomorrow.

All 10 people spent at least an hour talking about health insurance, "Doughnut
holes", the VA, and lots of other things related to the abysmal health system
in the US.

It occurred to me I've never heard such a conversation in Australia, but it's
simply automatically part of life that you get good care.

------
geomark
My own experience in Thailand is similar to the author's in India: see a
doctor on short notice, prices quoted in advance, short wait time for surgery,
prices low enough to pay out-of-pocket. The icing on the cake is how friendly
and warm the medical care is. My biggest fear when I visit the US is that I
will get sick or injured and be subject to that awful system. I lived in the
US most of my life, had excellent insurance, and had routinely poor
experiences with healthcare.

------
anilgulecha
My wife is a Dentist in Bangalore, India, and it's amazing what I hear.
Basically Cost(Flight to india + treatment cost) < Cost(Treatment in US).

The more you think about it, the more crazy it seems on multiple levels.

Edit, typed < instead of >.

~~~
vinceguidry
I went to get dental work done in Medellin, Colombia. Two whitening
treatments, perhaps a dozen fillings. My Atlanta dentist wanted to do an inlay
on one of my teeth. I'd already had two done that year and just couldn't
afford to have them keep working on my teeth.

When I got to Medellin, my dentist did not want to do the inlay, said it was
too invasive and that he would rather fill it.

It cost less to fly to Medellin, get all my work knocked out, than it would
have for just the one inlay. And I absolutely believe that my Colombian
dentist, who spoke English quite well, did better work than the Atlanta guy
did. My teeth look better than they have in years.

I will never again have significant medical procedures done in the US.

~~~
luciusism
Would you be willing to disclose the place you went?

~~~
vinceguidry
Of course!

This guy:

[http://medellindentist.simpl.com/index.html](http://medellindentist.simpl.com/index.html)

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kra34
Your treatment in the US would have involved something like 5 doctors,
$100,000 billing (probably not payments since those things are only vaguely
related) and 2+ years of your time.

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tahoeskibum
One thing I've never understood about the US system is why do the doctors
charge more for paying cash e.g. $200 for a visit, whereas insurance
reimburses them less than half e.g. $80. In everything else e.g. car repairs,
the cash price is always lower than insurance covered price. Any ideas why
this is so?

~~~
chimeracoder
> In everything else e.g. car repairs, the cash price is always lower than
> insurance covered price

For starters, insurance smooths risk. It is not there to save you money. By
definition, insurance will _always_ cost more than than paying out-of-pocket
_in the long run_ [0]. Think of insurance as a luxury that mitigates (but does
not eliminate!) the worst-case scenario for you. It costs more (a premium[1])
because this luxury has value to you.

The fact that this does not always apply to health insurance is a sign that
health insurance isn't entirely (in the economic sense) insurance; we just
happen to use that word.

> One thing I've never understood about the US system is why do the doctors
> charge more for paying cash e.g. $200 for a visit, whereas insurance
> reimburses them less than half e.g. $80.

In general, Medicare and Medicaid reimburse the least - the amount that they
reimburse is actually less than COGS (not on all individual services, but in
the aggregate, it amounts to 7% less)[2]. As a result, providers have to
overcharge private insurers and uninsured patients in order to cover their own
costs.

The price that you see on your bill is basically a starting point for
negotiations. A company like Aetna will say "okay, there's no way we're paying
that, but we _will_ pay you 250% of what Medicare reimburses for the same
procedure".

As an uninsured patient, you can do this as well _if_ you know to ask. It's
less of a practice for outpatient care, since that tends to cost less and also
have more predictable costs associated with it, but for (e.g.) unexpectedly
large bills for inpatient care, you can _always_ just tell them "I will pay $X
today in cash if you reduce the bill to that amount." They'll always be
willing to do it, because they literally do not care about the money that they
get from uninsured patients - the large bill is intended to be received by an
insurance company, not by an individual.

[0] ie, on an infinite time horizon.

[1] The fact that your fixed monthly payment to an insurer is also called a
premium is not a coincidence.

[2] To preempt the inevitable question: COGS refers to the direct costs of
providing a service, so this is _before_ even accounting for the fact that an
outpatient office has to pay rent, pay its staff, etc.

~~~
JamesBarney
_In general, Medicare and Medicaid reimburse the least - the amount that they
reimburse is actually less than COGS (not on all individual services, but in
the aggregate, it amounts to 7% less)[2]. As a result, providers have to
overcharge private insurers and uninsured patients in order to cover their own
costs._

I don't understand how doctors paying less to medicare/medicaid causes them to
have to overcharge other customers. If they are not making money on Medicare
or Medicaid patients it's my understanding they aren't forced to see them.

~~~
chimeracoder
> If they are not making money on Medicare or Medicaid patients it's my
> understanding they aren't forced to see them.

Sort of.

It's less the case for outpatient practices unaffiliated with any hospital
network, which is why the disparity between insured cost and out-of-pocket
costs for those practices tend to be smaller. But unaffiliated outpatient
practices are a dying breed.

For hospitals, it's more complicated. In theory, this would be true. In
practice, almost all hospitals other than the ones the VA operates do take
both Medicare and Medicaid because of a confluence of other regulations that
makes it unfeasible to refuse care to them. That said, despite this, the
amount of money that hospitals lose on public insurance has increased to the
point where a number of large hospital networks _have_ discussed rolling back
the services they offer to Medicare patients (such as outpatient care) or even
cutting it off entirely.

~~~
JamesBarney
_For hospitals, it 's more complicated. In theory, this would be true. In
practice, almost all hospitals other than the ones the VA operates do take
both Medicare and Medicaid because of a confluence of other regulations that
makes it unfeasible to refuse care to them. That said, despite this, the
amount of money that hospitals lose on public insurance has increased to the
point where a number of large hospital networks have discussed rolling back
the services they offer to Medicare patients (such as outpatient care) or even
cutting it off entirely._

Would you mind either explaining the regulations or pointing me at some
sources that explain the regulations that bind hospitals into paying for
Medicare and Medicaid? And by affiliated, does that mean has admitting rights,
or is owned by the hospital network?

Sorry not trying to be argumentative just trying to learn about the convoluted
world of healthcare.

------
MistahKoala
I wish there was a site like NomadList, but for medical tourism. I'm up for
going further afield for treatment, but the lack of information and good local
knowledge makes it riskier than I'd like.

------
veritas213
Cant really speak about orthopedic issues but have had some experience when my
partner had cosmetic surgery abroad. Cosmetic surgery makes up a significant
chunk of treatments and is much more of art than science. There is no way I
would ever risk having surgery anywhere before i knowing all the facts. My
partner had a face and neck lift from a "reputable" doctor in Los angeles and
honestly looks worse afterward than he did before. About 5 years he became
painfully aware that he needed it done again so he went to a well-regarded
surgeon in Bangkok that really improved his appearance and cost about half as
much. [http://www.thaimedicalvacation.com](http://www.thaimedicalvacation.com)

One interesting thing about her experience was that he was told by the doctor
in Thailand that he would not be able to offer a surgical facelift since he
already had one 5 years earlier. It was very interesting to see doctors saying
no rather than risking poor results with multiple surgeries. A person like
Joan Rivers is a good example of what can happen when you have way too many
surgeries.

Overall though my opinion is that for rare or esoteric conditions, there is no
place on earth better than the US. However for common elective or nonelective
surgeries, going abroad may not be a bad idea.

------
pimlottc
Nice piece, although it's a bit misleading to call this "medical tourism" as
the author was living in India at the time. Not that it discounts his
experience but I'm sure his local connections and familiarity made it easier
than it would be for the average American coming it from abroad.

~~~
jacquesm
It says he went back specifically to have the surgery.

~~~
yummyfajitas
Well, sort of. I would have gone back anyway (I had a girlfriend in Pune, as
the pictures sort of hint at, and no reason to be in the US), but my return
trip would have been slower and passed through more interesting places.

The OP is absolutely right that it would have been more difficult for me if I
knew nothing whatsoever about India. However, I probably could have paid a
couple of thousand USD more and OnP (the hospital I stayed at) would handle
things for me. I know they have a medical tourism office, albeit catering
primarily to gulf residents.

~~~
jacquesm
Good to see you on the other side of this. Any surgery is risky and if your
troubles are gone that's fantastic news. Are you still in touch with the
people there for check-ups or is it done for good?

~~~
yummyfajitas
I hope it's done for good, but being 6'6" means that there is always risk of
further injury. No point in a checkup - no pain = no problem.

I'm not deadlifting anymore, however.

~~~
ahh
FWIW deadlifting definitely helped, not hurt, after my back injury.

(Admittedly, I hurt it deadlifting with poor form, but fixing the form and
strengthening my back with it was the single biggest contributor to getting
better.) MMV, of course.

------
xacaxulu
Having traveled a lot for work, I've had the good fortune to have received
care in South Africa, dental work in Serbia and a number of regular treatments
in Mexico. I'm a born and raised US citizen though I also have an EU passport.
Any day of the week I'll sit on a plane for a few hours and pay less for much
better care in another country. Healthcare is a racket here. Better believe
when retirement comes I'm nowhere near the USA.

------
bambax
His symptoms sound very similar to the ones described in the book "The
mindbody prescription" by John Sarno.

I would very strongly recommend reading that book (which will set you back a
whopping $10) before undergoing any back surgery.

(I'm not a doctor, this is not medical advice, YMMV and all that. Still. If
you suffer from chronic back pain, or carpal syndrome, read the book.)

~~~
collyw
Bizzare being downvoted for suggesting trying a non invasive, cheap procedure
before opting for fairly serious surgery. Amazon's reviews give it 4.5 stars.

I assume its something similar to Thomas Hanna's Somantics from the name and
Amazon description, which would be something I would recommend people give a
try before going under the knife.

------
squozzer
Discussion of cost-effective alternatives is almost pointless now that we have
the ACA, which is effectively a transfer of wealth from individuals to
insurance companies for the sole privilege of breathing.

Oops, forgot at include dying also.

------
sillyhealthcare
This post is unrealistic in medicine, and really only works for less
serious/elective care issues, not primary medicine, or where doctor and
location choice actually matters.

As a starter: I'm woman with an extremely strong family history of breast
cancer before age 50. Standard clinical guidelines is to start doing heavy
monitoring 5-10 years before the youngest person in the family tree was
affected, since usually cases get progressively younger start dates. Since one
of the people was around age 32, I'm under the age of 30 and I go for
mammograms, ultrasounds, and MRIs every year as if I were a cancer patient
already.

Mammograms, ultrasounds, CAT Scans, MRIs, (any form of medical imaging
radiography) are actually a perfect example of how the market internationally
could be more efficient, but it turns out that's impossible. At its core we're
basically talking about photographs, something facebook manages to serve from
location a to person b that is nowhere near location a every day. Why couldn't
I go to any imaging place in the US, and have my images sent to the lowest
cost provider somewhere in india to be read and interpreted by a radiologist,
and then have the results sent back to me. Unlike Chris, I don't even have to
meet my doctor, all I have to do is send him images.

It turns out that medically this is blatantly difficult if not impossible to
do. The reasons are 2 fold

1) It turns out that age and variations in how and why the machines that used,
as well as technician speciality, matters a ton in image quality.

[http://www.kevinmd.com/blog/2010/09/mri-places-good-
quality-...](http://www.kevinmd.com/blog/2010/09/mri-places-good-quality-
machines-obsolete.html)

As a patient, I have no idea if the price I am being quoted is reflected of
image quality or price inflation (and this is before being read)

2)Quality of the radiology report is highly dependent on the MD reading the
images. This has been well studied since the early 2000s (one of the latest
examples being here:
[http://www.ncbi.nlm.nih.gov/pubmed/23737538](http://www.ncbi.nlm.nih.gov/pubmed/23737538)
) At under the age of 50 with dense breasts, I'm significantly more likely to
have imaging misread if I went into a community imaging location, even if they
had top notch equipment, because the radiologists do not have enough volume of
high risk cases to make sure I am not falling into false positives/recall on a
regular basis - which would mean even more imaging costs.

In order to effectively export my images, I would have to find a way to
duplicate part of the specialized cancer wing I go to. Cost savings actually
would be minimal - I'd be running more tests, seeing more doctors, and
probably have a delayed diagnosis if/when my expected inevitable happens
(which means more expensive drugs, longer treatment times, ect)

And while my example is specific to me, many people have similar sorts of
conditions where treatment location, equipment used, and people involved have
higher initial costs but lower lifetime costs for all sorts of conditions.
Pretty much any semi-serious disease falls into this category.

I'm game for better ways of paying (insurance does cover this, because as I
said, lower lifetime costs to them by paying for preventive care). I
experiment with things like telemedicine - I use a compounding pharmacy and
Specialized RN over the internet to manage acne that refuses to go away. I'd
totally go to the Caribbean for teeth whitening or LASIK.

None of these things need regular, serious followup, or run risks of painful
drawn out deaths/longer painful medical care with much higher costs if done
very incorrectly on a regular basis.

Medical tourism isn't the answer - understanding what these services are in
relationship to risk is.

