Outsourcing of Medical Surgery and the Evolution of Medical Telesurgery

abstract

With rising and often unreasonable costs in the U.S. healthcare system, Americans are becoming more inclined to seek cheaper alternatives. In some cases, Americans do not have to search for such alternatives on their own because their employers are offering them incentives to receive care from a foreign institution. Employees can go abroad to countries, such as India, in order to receive medical services for prices that are at least half of what the procedure would cost in the U.S. This emerging market seems to be beneficial to all involved except U.S. healthcare providers; however, this outsourcing of healthcare services sends a powerful international message. It seems that the U.S. has a healthcare system that cannot adequately serve all economic classes of the American public. In contrast, though India has the proper facilities and professionals, there are concerns regarding malpractice litigation, postoperative care, and possible negative effects on the Indian public. Having given consideration to all affected constituencies, it seems that the outsourcing of medical procedures is in the best interest of lower- and middle-class Americans as well as medical professionals in India. In reality, though medical tourism is receiving much attention, it will most likely not be a pressing concern for the American market in the near future. A widening discrepancy in the Indian public may, however, be cause for nearer concern. This new trend does foreshadow a push for more preventative changes in the business of U.S. healthcare, such as the development of information technology specific to the growing international healthcare market. Whereas, it will initially be beneficial to send patients abroad, with the evolution of technology, the latter ideal will instead be to have medical professionals abroad that care for patients located in the U.S.

introduction

The cost of healthcare in the United States seems to be approaching a level that is beyond the economic means of the general public. Even with insurance, expensive surgeries sometimes require thousands of dollars in out-of-pocket costs. Americans have found the cheaper alternative of seeking less expensive healthcare in a foreign country. This practice, which is often coupled with sightseeing and actual tourism, is appropriately referred to as medical tourism. Since there are plenty of advantages for both Americans and their foreign counterparts, medical tourism seems like the natural solution in the short run, and has the potential to become a rapidly growing market. However, when taking all constituencies into consideration, in the long run, this growing market could have some indirect, unfavorable side effects.

encouragement of foreign procedures

Perhaps the largest instigators in this recent trend are the employers. They could be playing a large role in the development of medical tourism simply by introducing the idea to their employees and, in some cases, even offering some economic incentive. In an effort to save on insurance fees, several companies have begun to promote foreign healthcare options.

Blue Ridge Paper Products, based in Canton, North Carolina, is one such venturous company. Their healthcare claims were initially projected to be $36 million by 2006; however, due to these foreign alternatives, their actual claims in 2006 were closer to $24 million (U.S. Senate Hearing, 2006). These savings will be to the advantage of the company and its employees because they will be able to internalize more revenue as well as keep wages reasonable.

Carl Garrett is a technician at a Blue Ridge paper mill who had plans to receive two medical operations in New Delhi, India. The 60-year-old needed both his gall bladder removed and his rotator cuff mended, and was delighted at the opportunity to avoid paying $10,000 in deductibles and out-of-pocket fees (Milne-Tyte, 2006). The cost for Blue Ridge was so low in comparison to the charge that the company would have incurred from U.S. medical fees that they actually offered to return a portion of their savings to Garrett.

In another case, Howard Stabb, a successful business owner, sought physicians in India rather than in the United States. Stabb had chosen not to have health insurance and found that he could save over $150,000 by receiving heart surgery out of the country. He brought a patient advocate with him, and both of them agreed that his decision to seek services abroad was best for both his personal well-being and for the financial stature of his company (U.S. Senate Hearing, 2006).

The Preference Towards India

One might wonder, of all the third-world countries where one might be able to receive care, why would India be a good choice? Why would the global leader in importing foreign patients be half-way around the world? Though a possible reason could be coincidence, as in, Indians were the first to create such a market, there are more likely, tangible reasons for this phenomenon. For instance, there is less of a language barrier in India as opposed to some other possible foreign destinations. Most Indians begin learning English in school at a young age, so odds are that the healthcare professionals would be able to communicate with an American in English. Also, helping to make their foreign patients feel secure with the care that they will be receiving, many Indian physicians have been trained in the west (Rai, 2006). Much American hesitation to travel abroad for care comes from uncertainty about the quality of care and knowledge and experience of the foreign physicians. Thus, knowing that an Indian physician has an American medical education would make the possibility more appealing.

Not only might the qualifications of the physicians testify to the care that they can provide, but the experiences of former patients can also be a strong point of persuasion. If individuals that are considering receiving care abroad know someone that can give a recommendation based on experience, they are much more likely to do it themselves. With the volume of medical tourism in India, half a million patients per year and growing, they have a large constituency that can vouch for the quality of care provided in the country (Hutchinson, 2005). Maggie Ann Grace, patient advocate for Howard Stabb, has stayed with patients both in India and the United States. She noted in a statement to the U.S. Senate that she, “would sooner leave her loved ones in the care of doctors and nurses in the Indian Hospital” (U.S. Senate, 2006). She attributed this opinion mostly to the fact that nurses in the U.S. are too busy and because of this, care is given based on the level of the patient’s severity and the nurse’s schedule.

Cost is also to India’s advantage, not only in comparison to U.S. prices, but to other countries as well. In a 2005 comparison of estimated fees for a coronary artery bypass graft surgery, India’s more expensive hospital was still $15,000 less expensive than a Mexican hospital and $5,000 cheaper than Thailand (U.S. Senate, 2005). Thus, for reasons that range from financial to human interaction, India is a strong competitor in the international market for medical tourism.

The American Perspective

American disdain for the healthcare system has the potentional of becoming a detriment to U.S. society. The situations of both Carl Garrett and Stabb seem to favor medical tourism. It is a favorable option for the patient and their employer, but are there possible adverse affects? On a larger scale, considering all constituencies both directly and indirectly involved, there is a variation in those that benefit from this particular form of outsourcing. For the growing constituency that benefits from and is in favor of medical tourism, there is an opposing set of constituencies that will find this disadvantageous. From 2002 to 2005, there was an increase of 350,000 foreigners that traveled to India for care, this number is projected to increase by 30% each year (Hutchinson, 2005). If this pattern of receiving healthcare abroad does continue to progress, it does not present a sustainable future for the present state of our domestic healthcare system.

Howard Stabb was operated on in India, stayed for a month, and returned with a positive impression of the care provided. His cardiologist in the States reported that he was healthy and that the operation had been successful (U.S. Senate, 2006). That was the best option for Stabb personally, but on a societal level, Stabb’s, advertisement for medical tourism may have a negative impact.

Carl Garrett received his operations in the U.S. instead of in India as intended, due to strong opposition. Garrett is part of the United Steelworkers Union, who saw this growing trend toward medical tourism as an excuse to lower the quality of care and a denial of the right to safe healthcare. Stan Johnson, a speaker for the Union, stated that outsourcing healthcare would lead to corporate profiteering and that if we allow traveling abroad for treatment to remain a feasible option, it may one day become the only option (Milne-Tyte, 2006).

Bruce Cunningham, president of the American Society of Plastic Surgeons, presented other concerns, while providing what would most likely be the shared opinion of many American physicians on this subject. He could understand the desire to receive healthcare at a lower cost, but warned of the potential to increase risks (U.S. Senate, 2005). Travel done shortly after having surgery can be risky. Also, many procedures require follow-up care; if an American provider will be administering postoperative care, they should be found and agree to provide care before the patient leaves the country.

There was no evidence found that would justify American physicians having a fear of losing revenue. On the contrary, American physicians and hospitals may begin to feel some reprieve from a diminished patient load. This seems to be the optimistic view of UK physicians. In 2002, it was the National Health Service (NHS) of the UK that began to encourage citizens to seek care abroad in order to alleviate long wait lists (Maini, 2005). Also, patients that would not be eligible for a procedure under NHS would travel abroad to receive it. Thus, it seems that for the present time, such outsourcing is beneficial. For long-term concerns, there is comfort in the fact that for many procedures, proximity is essential. For instance, childbirth and emergency care are not services that could withstand the 20-hour flight.

IndUSHealth, one of many companies that coordinate visits for medical tourists, caters to interested Americans by providing direct information and offering assistance with planning the trip and procedure. Their Web site will most likely convince Americans with limited financial resources that this is their best option for receiving medical care. The company assigns each patient a personal case manager that handles the details of their visit (IndUSHealth site, 2005). Their Web site is subjective; it sheds a positive light on all aspects of receiving care in India. Interested patients should investigate their own reasons for going and whether or not they find any ethical bias against it. Overall, the American perspective is torn. Not necessarily a question of quality vs. cost, there are several factors and variables to consider.

The India Perspective

The healthcare system in India is complex. The healthcare facilities are divided first into two categories, government and private, and under each of those two categories are three main branches: tertiary, secondary, and primary (the lowest level of care) (Van Hollen, 2003). The government institutions are generally considered inferior to the private due mostly to overcrowding, less funding, and less expensive care. As one goes further from the city, the medical facilities become less technologically advanced, have minimal staff, and lowered sanitation standards. The divide between the private and public sector is growing. In fact, the spending on public healthcare is the sixth lowest in the world. On the other hand, India is among the top 20 nations for spending in the private sector (Nundy & Sengupta, 2005). This is due to spending on healthcare being a lower priority. To compensate, the government encourages growth in the private sector. The government uses subsidies and tax exemptions as some methods of encouraging the private sector. This increasing divide between public and private healthcare factors into not only the care provided, but also the providers of the care. Healthcare professionals prefer working in the private sector due to higher wages and a more pleasant working environment. It is this lack of interest in public sector employment that has propelled entrepreneurial endeavors such as venues for medical tourism, because the Indians involved in the development and implementation of these endeavors do benefit from them.

Unfortunately, there does also seem to be negative repercussions for Indian patients both in the private and public sectors. It seems probable that their care and access to the best physicians might be compromised by the influx of foreigners with more elastic checkbooks. One large downfall of the private sector is that it is not regulated so there are no standards of quality or costs (Nundy & Sengupta, 2005). Thus, their success is measured by profit rather than the actual care being provided. Unfortunately, the private sector also tends to pull the focus away from the public health situation. Since India has plenty of internal health concerns such as widespread diseases and rural communities with minimal healthcare facilities, it seems that a greater focus should be put on the public sector. The problem is that the attraction to the private system is prevalent both to the care providers and patients. In such a profit driven situation, to make this shift from privately to publicly focused is challenging.

comparative data

All Indian hospitals involved are approved by the WHO supported Joint Commission International. The mission of the Joint Commission International is to improve the safety and quality of care in the international community. Many contributing Indian hospitals are part of a private national chain; for instance, the Apollo Hospitals in Chennai and New Delhi and the Wockhardt Hospitals, one of which is in Mumbai. There is also a chain in Delhi, Fortis Healthcare.

Just as the market for medical tourism has grown in India due to enticing profit margins, reciprocally, American consumers are similarly convinced by the savings. All of these options have a major financial advantage over U.S. providers.

Americans also benefit from some insurance relief since some insurance companies that traditionally only covered emergency, out of country procedures have evolved to a coverage plan for non-emergency situations. BCBSAZ, Cigna, Humana, and Aetna are examples of providers that support the concept of receiving healthcare abroad (personal communication, March 3, 2007). Aetna would only be willing to cover a non-emergency if it is proven to be medically necessary. Perhaps the growing popularity of coverage for procedures conducted abroad has a correlation to the rising insurance premiums. According to the Kaiser Family Foundation, insurance premiums have risen 87% in the last 6 years (Galles, 2007). In 2006, the average annual premium for coverage for a family of four was $11,500 (Fitzpatrick, 2004). That means that the premium was greater than the gross earnings for a full-time minimum wage worker. It would be economically impossible for them have insurance, which explains why 43 million people in the U.S. do not have health insurance (Hutchinson, 2005). This trend of forcibly keeping people from having insurance seems to be a force that is perpetuating the outsourcing of medical care.

The malpractice issue

Speaker of the Union, Stan Johnson, expressed an additional concern that most would not consider, having already been strongly convinced by the savings that receiving care abroad affords. However, consumers should consider the possibility of a malpractice lawsuit and who, if any, would be the responsible party. In accordance with their agenda, IndUSHealth has a reasoned response to concerns about malpractice litigation. They claim that India has a similar court system to the U.S. and American patients have the right to file cases there. In reality, however, it seems that though American patients would have the right to file a case in India, the proceedings of a lawsuit would differ from the American process. The major difference between the systems of the two countries is that in the U.S., such a case would be tried in a state court, while in India there are more specific consumer courts. The trend in U.S. courts is to present the patient as victimized and almost guilt the jury into awarding the patient a large sum of the rich doctor’s income. In India, on the other hand, there is a less-biased perspective. Awards are given based on damage; lawyers are not permitted to accept cases that may have facetious intentions. Culturally, doctors in India are so highly respected that most patients would not challenge the decision of their doctor, though there is a possibility that India’s system may be swaying toward the favor of the consumer. In 1992, the Kerala High Court proposed an extension to the Consumer Protection Act to include malpractice and negligence. Due to opposition from physicians, the proposal was reviewed by the supreme court but, to the favor of consumers, was upheld. It was not only upheld in Kerala, but courts were established in all states to handle the complaints of consumers (Studdert, Mello, & Brennan, 2004).

However, there has not been much change toward the American mentality of a more persuasive litigation process. This is dually reflected in the contrasting price of malpractice insurance. According to the Pacific Research Institute, Indian doctors pay $4,000 per year for insurance while American doctors have been known to pay 25 times that amount (Brunell, 2007).

Although this may seem to correlate with the view of foreign malpractice laws as being too relaxed, within both healthcare systems there is a problem of keeping record of errors and any resulting injuries. There is currently an emerging program in the U.S. to hold doctors and hospitals accountable for recording errors (Studdert, et al., 2004). No such program has been initiated in India, but perhaps that will change with an increased influx of foreign patients. A responsible system to track liability would, in turn, keep malpractice suits in both countries honest and less biased.

Overall, even if an American patient were willing to chance a system that had no tendency to be in the consumers’ favor, considering the financial aspect of such a process may cause them to reconsider. Financially, there is the added cost of traveling back and forth, as well as lawyer’s fees. Also, if compensation is awarded, it would be a much smaller amount than one would expect in the U.S. (Milne-Tyte, 2006).

Technological innovations

Consider a more cooperative approach to cross-cultural care, where liability is spread amongst providers in two separate countries; there are several technicalities that tend to hamper innovation in healthcare. However, new developments may also serve as solutions to greater struggles. It seems that advances in technology will correlate with the popularity of medical tourism.

Telesurgery, a specific branch of telehealth, provides the opportunity for surgeons that are physically located in different locations to communicate through operative videoconferencing. One surgeon observes the procedure through a camera and then offers visual and auditory feedback to the surgeon at the operating site (Cheah, Lee, Lenzi, & Goh, 2000). Among the more developed teleradiology, telepathology, and teleoncology, telesurgery seems to be the branch of telecommunications that is directly applicable to medical tourism. International telesurgery proved to be successful in two laparoscopic cases between the United States and Singapore. More specifically, an experienced U.S. surgeon observed a less experienced surgeon perform both a radical nephrectomy and a varicocelectomy (Lee, Liew, Fabrizio, Li, Jarrett, & Kavoussi, 2000). This practice would be beneficial to the medical tourism market both by alleviating the distrust of foreign physicians, as well as keeping cost minimal by still undergoing the procedure in a foreign institution. A more recent 2003 study of procedures conducted between the United States and Brazil noted a feasible future for telesurgery. In two cases of telepresence surgery, a U.S. surgeon directed a robot attached to a laparascope in a bilateral variococelectomy, and the other robot was used for needle placement in a percutaneous nephrolithotomy (Rorigues, Mitre, Lima, & Fugita, 2003).

However, there are barriers to implementing this technology, the language divide, for one. One would assume the physicians in this example corresponded in English, but it cannot always be assumed that that will be feasible. Additionally, the cost of higher bandwidth communication lines is still expensive, which makes it difficult for such technology to access foreign countries (Lee, & Png, 2000). The financial emphasis on healthcare is truly an overpowering barrier, which explains why the success of telehealth relies on the private sector. It seems that an established relationship with a university that is willing to do research and provide resources, as well as a partnership with several private healthcare organizations to incorporate, is key to establishing a successful telehealth program. Not only is a structural foundation necessary, but a substantial need for such an innovation is also required. The success of the UltraClinics telehealth solution to mammogram screening was due to the yearly demand of over 48 million mammograms and the one million additional that require biopsy (Weinstein, et al., 2007). As of now, though there are crowded emergency rooms and stymied appointment schedules in the U.S. and UK, the demand is not overpowering, thus, there has been no push for the combination of medical tourism and telesurgery.

Beyond financial barriers it seems that in the future, when demand as well as technology has increased, this may be a strong asset to the growing medical tourism market. Telesurgey supplements both problems of communication and postoperative care. Comprehensive hospital information systems, such as the system implemented at the U.S. Veterans’ Affairs institutions, have initiated electronic health records. With the correct considerations of patient privacy, the ability to transfer records with such technological ease will improve communication and understanding across country borders. Based on the UltraClinics example, increased use of technology can keep the patient more informed, accelerate their care, and allow more time for the physician to care pre- and postoperatively (Weinstein, et al., 2007). There are more benefits than detriments to the globalization of healthcare, but it will require a more cooperative attitude toward sharing advances in research, techniques, and technologies.

conclusion

Medical tourism will most likely continue to grow in popularity. Though it is negative propaganda for the arguably outrageous cost of healthcare in the U.S., it is helping to ease some strain on the American system. Essentially, American physicians are keeping most of the patients that can afford the procedure, losing middle-income patients that opt to save money abroad, but still have the burden of the low-income population that cannot afford the less-expensive option. This seems to prove that the medical environment in the U.S. is now driven by money rather than the desire to provide quality care to each patient. However, the money lost (see Table 8.1) to foreign markets seems to have little effect on the U.S. healthcare market. As long as there are overcrowded emergency rooms and the need to schedule doctor’s visits months in advance, like the UK, the U.S. will probably consider this new trend to be beneficial. The fact that the market in India has a 30% consumer increase yearly is significant, but not enough to severely damage the American market in the near future. If we do come to a breaking point where benefit becomes burden, the U.S. healthcare system would be forced to make some changes, such as the compromise of telesurgery, that would attract the middle-class constituency and minimize the outsourcing of medical services.

Table 8.1. Chart: U.S. Senate, 2005)

No major preventative changes have been made as of yet, due mostly to one major barrier; policymakers and government officials cannot agree on the best way to control costs. Some possible solutions would be implementing price controls or strict budgets (Fitzpatrick, 2004), although it may be time to consider a system that provides healthcare to every American citizen. With millions of uninsured citizens, people will avoid seeking care until it is necessary. The U.S. still spends more on healthcare than any other industrialized nation. As with many shifts toward outsourcing, the need for change originated in the home country, which led to the need to seek out supplementation, not substitution, in foreign markets.

future research

There is still much to be determined about the future of medical tourism and economic solutions to healthcare, domestically. Though price difference and the savings to be had abroad are well advertised, there are few documented patient experiences. It would be beneficial, both for prospective patients and providers, to have a well-rounded description of the medical tourism industry. Inclusive in such a description should be what drove each patient to seek care abroad, their experience throughout the process, whether they benefited overall from the savings and what recommendations they would give to prospective patients. Such documentation should also include reasoning behind choosing the country in which care was given, it seems that regional specificity may emerge along with this growing trend (i.e., for cardiac surgery one would seek care in Mexico, while facilities in India would specialize in dentistry). Realistically, it would be to the advantage of foreign providers to specify their fields of care, in the effort to heighten the quality of care that they can provide. Though this may reduce some of the competition in the market, it will increase the appeal to American consumers who are wary about the quality of care provided abroad.

Telesurgery, an innovative technology that may prove to be a solution to several problems, has already been successful in a few operations. However, there will have to be a great deal more data collected to ensure the usefulness of this innovation. Additionally, the cost of such a procedure would have to be reduced before it would be willingly adopted into the market. Overall, since this market is still in its fledgling stages, there is little data from which concrete conclusions can be made, making further research essential to future progress.