Tag Archives: international

Implementing International Medical Providers Into The U.S. Workers' Compensation System, Part 3

This is Part 3 of a multi-part series on legal barriers to implementing international providers into Medical Provider Networks for workers’ compensation. Previous articles in the series can be found here: Part 1 and Part 2. Subsequent articles in the series will be forthcoming soon.

Heather T. Williams agrees with critics, that medical tourism is a trade-off for consumers, allowing them to opt-out of increased regulation in favor of fewer restrictions and greater cost savings. Factors unique to the medical tourism industry will help preserve the quality of patient care and insulate patients from the regulatory pitfalls critics fear. Williams points to the benefits of medical tourism as providing patients with substantial cost savings, due in part to lower labor costs overseas.43

The cost savings in the context of inflated health care costs in the U.S. indicates why patients are driven abroad to seek medical care. How much of a cost savings medical tourism offers patients can be seen in how much hospitals charge for major surgical procedures such as cardiac surgery, partial hip replacement, knee replacement, and rhinoplasty. A hospital in India charges $4,000 for cardiac surgery, compared to $30,000 in the U.S. Hospitals in Argentina, Singapore or Thailand charge $8,000 to $12,000 for a partial hip replacement that would otherwise cost twice that much here. Singapore and Indian hospitals charge $18,000 and $12,000 respectively for knee replacement that normally cost $30,000 in the U.S. Finally rhinoplasty that costs $4,500 in the U.S. costs only $850 in India.44

Though all patients can benefit, medical tourism’s cost savings are more likely to benefit those with inadequate health insurance coverage.45 Lower-middle-class individuals, who typically have sufficient means to pay for reduced-price care out-of pocket, will benefit most from medical tourism.46 This is a point to bear in mind with regard to workers’ compensation, as many claimants are generally lower-middle-class.47

Medical tourism disproportionately benefits uninsured or underinsured individuals,48 but they are not the only ones benefitting from cost savings from medical tourism.49 Self-insured employers and private insurance companies have begun integrating medical tourism into their policies. It is attractive to small businesses as well.50 Medical tourism is expanding as self-insured employers and insurance companies have integrated medical tourism into their policies.51 For instance, Blue Ridge Paper Products of Canton, North Carolina sought to send an employee overseas for gallbladder and shoulder surgery.52 They offered him 25% of the savings, but the United Steelworkers prevented them from doing so and union workers were removed from the pilot program.53 54

State governments, looking to save money anyway they can may accept medical tourism for their state employees. A bill introduced into the state legislature in West Virginia in 2006, (H.B. 4359), would have encouraged state employees covered by the Public Employees Insurance Agency (PEIA) to utilize Joint Commission International accredited foreign hospitals, receive travel reimbursements for themselves and a companion, and participate in the savings with a cash rebate.55 56 The bill is still pending in the House Banking and Insurance committee.57

Large HMOs and health insurance companies have established plans to allow patients to obtain low-cost services overseas.58 BlueShield and Health Net of California, United Group Programs of Boca Raton, and BlueCross and BlueShield of South Carolina have offered such plans for travel to Mexico and Thailand for treatment.59 The effect of financial incentives on American’s willingness to travel for medical care is evident in a 2007 nationwide telephone survey of a representative sample of 1,003 Americans in which 38% of uninsured and one-quarter of those with insurance would travel abroad for care if the savings exceeded $10,000. One-quarter of uninsured, but only 10% of those with insurance would travel if savings were between $1,000 and $2,400. Fewer than 10% would travel to save $500 to $1,000, and no one would do so to save $200 or less. This represented a potential market share of 20-40 percent for non-urgent major surgery.60 61

Medical tourism is fast becoming a feature of American health care. In the next few years, more and more Americans will be going overseas for medical care. It is only a matter of time before medical tourism’s mark is felt on another arena of American health care — workers’ compensation.

43 Williams, 611.

44 Herrick, 8.

45 Williams, 614.

46 Ibid, 614.

47 Juan Du and J. Paul Leigh, “Incidence of Workers Compensation Indemnity Claims Across Socio-Demographic and Job Characteristics,” American Journal of Industrial Medicine, 54 (2011): 758-770. The study suggests that low socioeconomic status was a predictor of reporting workers compensation claims, but did not include income levels; although it is possible to extrapolate from the data presented that the subjects were generally lower middle class or working class.

48 Williams, 614.

49 Ibid, 615.

50 Ibid, 615.

51 Ibid, 615.

52 Boyle, 43.

53 Ibid, 43.

54 Williams, 616.

55 Ibid, 44.

56 Nicolas P. Terry, “Under-Regulated Health Care Phenomena in a Flat World: Medical Tourism and Outsourcing,” Western New England Law Review, 29, no. 29 (2007) 427.

57 West Virginia Legislature website, (2006).

58 Williams, 616.

59 Boyle, 44.

60 Herrick, 2.

61 Arnold Milstein and Mark Smith, “Will the Surgical World Become Flat?,” Health Affairs, 26, no. 1 (2007): 138.

Implementing International Medical Providers Into The U.S. Workers' Compensation System, Part 2

This is Part 2 of a multi-part series on legal barriers to implementing international providers into Medical Provider Networks for workers' compensation. Part 1 of the series can be found here, and Part 3 can be found here. Subsequent articles in the series will be forthcoming soon.

Quality and Medical Tourism
Considerations of cost are one reason why patients go abroad for medical treatment. Patients also seek medical care abroad for the quality of care received at foreign hospitals, which is the primary concern of medical tourism critics.13 Fears of poor quality result from stereotypes regarding doctors and facilities in developing countries.14 The quality of care available at many of the common medical tourism destinations are comparable to that available to the average U.S. patient; also death rates and adverse outcomes for cardiac patients in Indian and Thai medical tourist hospitals are comparable to, and in some instances, lower than those at American hospitals.15

Typically, the effectiveness and safety of health care services delivered to patient populations in the U.S. is how “quality of care” is measured. However, quality is generally difficult to measure or define.16 Also, comparing safety on a state or local level is practically impossible.17 Federal policy makes reporting adverse events at medical facilities voluntary, and few states require reports to be made public.18 Reports, where made, are usually incomplete as well.19

Apollo Hospital Group and Wockhardt Hospitals in India (affiliated with Harvard Medical School), and Bumrungrad International Hospital in Bangkok, provide a better level of care than most community hospitals in the U.S., according to Harvard Medical International, Inc. (now Partners Harvard Medical International).20 21 For at least one common procedure performed in the U.S. today, coronary artery bypass graft (CABG), the mortality rate for Apollo Hospital Group and Wockhardt Hospitals is less than 1%, whereas in several California hospitals, the mortality rate ranged from 2.1% to 13.8%.22

The disclosure of recognized quality indicators, oftentimes not done in the U.S., is true for many hospitals overseas.23 24 However, those hospitals that compete on an international level do disclose quality indicators.25 26 U.S.-based hospitals such as Dartmouth Hitchcock Medical Center in New Hampshire and Cleveland Clinic in Ohio post quality indicators on their hospital websites.27 28 National University Hospital in Singapore discloses information that their quality compares favorably internationally.29 30 The Apollo Hospital Group in India, has devised a clinical excellence model to ensure its quality meets international health standards in all of their hospitals;31 32 other Indian hospitals are creating standards for reporting performance measures.33 34

Perhaps the best example of this is Bumrungrad International Hospital in Thailand. Bumrungrad is a modern multispecialty hospital with 554 beds. Its main building was built in 1997 to conform to U.S. building and hospital standards. Bumrungrad tracks more than 500 quality and patient safety measures.35 Over 100 of their doctors are board-certified by U.S. medical specialty groups, as they have been trained in the U.S. or the U.K.36 37 Many of them have licenses from Australia, Europe and Japan.38 Bumrungrad is also accredited by the Joint Commission International.39

The establishment of the Joint Commission International (JCI), the international arm of the Joint Commission, has meant that the quality of hospitals overseas has been assessed by the Commission and that the health care offered at those hospitals conforms to “international quality.” Countries such as Thailand and India recognize the value of standardization and certification, and have established their own national accreditation bodies.40 Therefore, the issue of quality of care at international hospitals that cater to medical tourism should not be a major factor, and will only improve as more nations comply with international standards, and their hospitals are equipped with the latest technology and most-highly skilled and trained medical providers.

Additionally, medical tourism will relieve the critical shortages in medical staff for physicians, specialists and nurses. In 2000, the demand for registered nurses exceeded the supply by more than 100,000, and by 2020 this shortage will increase to more than 200%.41 And as the Affordable Care Act kicks in in the next few years, the demand for services as more individuals are covered will put considerable strain on an already strapped health care system. This will affect quality in U.S. hospitals as the shortages become more acute.

Putting the issue of quality aside, another fact to consider is the number of people participating in medical tourism. An estimated 500,000 Americans traveled abroad for treatment in 2005, the majority of them to Mexico and other Latin American countries. Americans were among the 250,000 foreign patients seeking care in Singapore, 500,000 in India, and as many as 1 million in Thailand. The impact of these numbers is considerable as medical tourism grossed approximately $60 billion worldwide in 2006, and was estimated to rise to $100 billion in 2010.42 Medical tourism is growing very rapidly and is expected to grow even more so in the coming decade.

13 Heather T. Williams, “Fighting Fire with Fire: Reforming the Health Care System Through a Market-Based Approach to Medical Tourism,” North Carolina Law Review, 29 (2011): 627.

14 Ibid, 628.

15 Ibid, 628.

16 Ibid, 628.

17 Ibid, 629.

18 Ibid, 629.

19 Ibid, 629.

20 Devon M. Herrick, “Medical Tourism: Global Competition in Health Care”, (NCPA Policy Report No, 304, Dallas, Texas, 2007), 14.

21 Toro Longe, “The Ethical and Legal Complexity of Medical Tourism: Questions of International Justice, Economic Redistribution and Health Care Reform,” (master's thesis, Loyola University of Chicago, 2010), 9.

22 Herrick, 13, Cardiac Surgery Mortality Chart, Figure IV.

23 Ibid, 14.

24 Longe, 10.

25 Herrick, 14.

26 Longe, 10.

27 Herrick, 14.

28 Longe, 10.

29 Herrick, 16.

30 Longe, 10.

31 Herrick, 16.

32 Longe, 10.

33 Herrick, 16.

34 Longe, 10.

35 Ibid, 9.

36 Boyle, 44.

37 Longe, 9.

38 Ibid, 9.

39 Ibid, 9.

40 Leigh Turner, “'First World Health Care at Third World Prices': Globalization, Bioethics and Medical Tourism”, BioSocieties 2, (2007): 311.

41 Williams, 627.

42 Herrick, Executive Summary.

Implementing international medical providers into the U.S. workers' compensation system, Part 1

This is Part 1 of a multi-part series on legal barriers to implementing international providers into Medical Provider Networks for workers' compensation. Part 2 of the series can be found here, and Part 3 can be found here. Subsequent articles in the series will be forthcoming soon.

Introduction
Throughout the debate leading to the enactment of the 2010 Affordable Care Act (ACA), one area of health care has been relegated to the sidelines — the rising cost of workers' compensation claims. One major factor for the increase of workers' compensation claims costs is the rise of medical costs associated with those claims. The average medical cost per loss time claim in workers' compensation in 2008 was $26,000, and medical losses in that year represented 58% of all total losses.1 2 Since 2008, the average medical cost has risen steadily, increasing at a moderate rate3, as shown in Figure 1.

Figure 1 — WC Medical Claim Cost

WC Medical Claim Cost

20011p — Preliminary figure based on data valued 12/31/2011

In the past twenty years, from 1991 to 2010, the average medical cost per lost-time claim has gone from $8,100 to $26,900. In 2001 it increased to $15,900, and by 2005 it had gone up to $21,300. Given this trajectory, medical costs for workers' compensation will continue to rise, perhaps even reaching $50,000, if medical costs cannot be controlled. With all the workers' compensation system calls for reform, one possible solution has yet to catch on; implementing international medical providers into workers' compensation.

Implementing international medical providers into the U.S. workers' compensation system sounds far-fetched; however, globalization is rapidly changing many industries around the world, and health care and workers' compensation should not be an exception to that change. A rapidly emerging segment of the global healthcare industry is medical tourism.4 Medical tourism refers to patients going abroad to seek low-cost treatment. As international travel becomes more affordable and less complicated, and the technology and standards of care have improved, medical tourism has become very popular.5

This development has led to the creation of commercial ventures that facilitate the process of providing medical services to their clients. The facilitators’ role is to choose the best location, the best hospital and the best physicians to perform the treatment or procedures the patient requires. It began primarily as an individual practice.6 However, more group health plans are adding medical tourism into existing plans, or offering health plans that include medical tourism and implementing international provider networks into their plans.7

The desire to seek care abroad is motivated by a desire to seek health care that is lower cost, avoids long wait times, or provides services that are not available in one’s own country.8 The skyrocketing cost of U.S. health care due largely in part to exorbitant administrative costs, the practice of defensive medicine, and weak preventative care, is a potent argument for seeking medical tourism.9 10 Countries that serve as locations for medical tourism also have lower labor costs,11 and that translates into considerable savings for the patient.12

Just as many legal barriers exist to doing business overseas, the implementation of international medical providers into U.S. workers’ compensation medical provider networks also presents many barriers. This series will attempt to examine a few legal and regulatory barriers currently preventing foreign medical providers from treating patients abroad for injuries resulting from work-related accidents. It is not intended to be a definitive discussion of the subject, but rather a starting point for further discussion. Currently there is no literature available on the subject of medical tourism and workers’ compensation, but it is hoped that such literature will be forthcoming. At the conclusion, support for the hypothesis that the globalization of health care and the move towards medical tourism should include workers’ compensation will be offered.

1 Barry Llewellyn, (2009, September). Workers’ Compensation Medical Cost Issues. Casualty Loss Reserve Seminar (presented at the meeting of the Casualty Actuary Society (CAS), Chicago, Illinois, September 14, 2009).

2 Dennis C. Mealy, (2009, May). State of the Workers’ Compensation Line. (Presented at the meeting of the Annual Issues Symposium at the National Council on Compensation Insurance, Boca Raton, Florida, May 7, 2009). Figures shown in the 2009 report for 2008 were adjusted in later years, so that in the latest report, the average medical claim cost per lost-time claims in 2008 was $255,000, as shown in Figure 1.

3 Dennis C. Mealy, (2012, May), State of the Workers’ Compensation Line, (presented at the meeting of the Annual Issues Symposium at the National Council on Compensation Insurance, Boca Raton, Florida, May 10, 2012).

4 Laura Hopkins, Ronald Labonte, Vivien Runnels and Corinne Packer, “Medical tourism today: What is the state of existing knowledge?,” Journal of Public Health Policy, 31, no. 12 (2010): 185.

5 Kristen Boyle, “A Permanent Vacation: Evaluating Medical Tourism’s Place in the United States Healthcare System,” The Health Lawyer, 20, no. 5 (2008): 42.

6 Heather T. Williams, “Fighting Fire with Fire: Reforming the Health Care System Through a Market-Based Approach to Medical Tourism,” North Carolina Law Review, 29 (2011): 615.

7 Ibid, 616.

8 Hopkins, et al., 185.

9 Boyle, 42.

10 Williams, 613.

11 Ibid, 613.

12 Ibid, 613.

Note: This series would not have been possible without the inspiration, enthusiasm, encouragement, and guidance of Kristen E.B. Montez, Esq., the Director of Legal and Regulatory Services of Satori World Medical in San Diego, CA. It was Kristen who answered my call on LinkedIn.com for assistance with a topic to write for my Health Law class. Her knowledge and experience in the area of medical tourism as a published writer on the subject was not only very valuable, but also very much appreciated. Her desire to assist me in writing it, and in getting it published, is something that I did not expect, nor imagined when I placed the online posting. She is a remarkable individual, and it is my pleasure to have connected and collaborated with her on this project.