Ticket to treatment

Dickerson is a Times staff writer.

When Andy Dijak injured his right knee playing tennis, he wasn’t surprised that he needed surgery. “It swelled up like a balloon,” said the 50-year-old West Lake resident.

The real shocker was the price tag: $12,000 to $15,000 to repair tattered cartilage. Dijak, a creative director for an entertainment company, has no health insurance, so he started shopping for a deal.

He found it in the northern Mexico city of Monterrey at Christus Muguerza High Specialty Hospital, owned by Dallas-based Christus Health. Here, the staff treated him more like a big shot than a bargain hunter. An English-speaking employee picked him up at the airport. Dijak recuperated in a private hospital room with a flat-screen television and a view of the peaks of the Sierra Madre. His surgeon recorded the operation on video and gave Dijak a DVD copy for his peace of mind.

Total cost, including airfare: $4,500.


“I got better care there than I would have in the United States, unless I were a billionaire,” he said.

Americans have long been willing to leave the country for bargain face-lifts and cut-rate dentistry. But now the availability of top-notch medical services at low cost is enticing a growing number of U.S. patients to developing nations for more sophisticated procedures. Most, like Dijak, are obtaining elective surgeries for ailments that aren’t life-threatening. Increasingly, they are seeking treatment for more serious conditions, including heart maladies and cancer.

Last year, 750,000 Americans traveled abroad for care, according to estimates by the Deloitte Center for Health Solutions, a Washington-based research center that’s part of the consulting firm Deloitte & Touche. Other analysts say the numbers are lower. But hardly anyone disputes that medical care, once a highly local business, is going global like never before. By 2010, Deloitte projects, 6 million consumers a year will venture outside the United States for medical treatment.

The idea of jetting off to India for heart surgery might strike some as a radical way to save money. But proponents say it’s a logical outgrowth of the globalization that’s reshaping the industry.

Already, offshore firms handle Americans’ medical records and read their X-rays. Top U.S. hospitals such as Johns Hopkins have established outposts abroad. Rising prosperity in many parts of the developing world is luring foreign-born, U.S.-educated doctors home to practice in modern hospitals catering to increasingly affluent consumers.

Nearly 200 institutions outside the U.S. have been certified by the Joint Commission International, an affiliate of the organization that accredits U.S. hospitals. Medical travel companies are springing up to link American patients with foreign providers eager to boost their profits.

Add a rapidly aging U.S. population and a shrinking medical safety net, and the notion of Americans looking elsewhere for treatment no longer seems such a stretch.

“This is going to be one of those things that starts slow and becomes pretty routine 15 years out,” said Arnold Milstein, chief physician for Mercer Human Resource Consulting.


The fact that 1 in 6 U.S. residents, nearly 46 million people, lack health insurance is well known. But soaring deductibles and increasing restrictions on coverage are driving even insured consumers to seek alternatives.

Mark Sawko’s insurer balked at paying to replace a bum knee the 50-year-old Arizonan injured back in high school. So he called a Tempe, Ariz.-based medical travel company called MedToGo. The firm arranged for him to have surgery last year in Puerto Vallarta, Mexico, where he spent $13,500 instead of the $50,000 quoted by a local orthopedic surgeon.

The owner of a company that makes industrial parts, Sawko competes every day with foreign manufacturers. He sees the same thing happening in medical care.

“I think we’re going to lose a lot of business to these other countries,” said Sawko, who has returned to playing golf without pain. “I’m American, so I’d like to keep things here. But no one was going to make it affordable for me.”


At present, the vast majority of U.S. medical travelers are cash-paying patients such as Sawko. But analysts say that’s changing fast as insurance companies and employers add foreign providers to their networks to slow runaway costs.

In Southern California, insurers Aetna, Blue Shield of California, HealthNet and PacifiCare have developed cross-border programs that allow members to seek treatment in Mexico. That means cheaper premiums for employers and smaller co-pays and other out-of-pocket expenses for members.

“A lot of small employers have been priced out of traditional coverage,” said Jim Arriola, president of Sekure Healthcare Inc., a Chula Vista, Calif.-based company whose plans cap services at a fixed dollar amount. “That same $1,000 benefit goes a lot further south of the border than it would in the U.S.”

Uptime Electronics Inc., a Whittier-based equipment repair company, recently began offering its 20 employees the option of going abroad for care. The company has contracted with Planet Hospital, a Calabasas medical travel coordinator that has relationships with providers in 13 countries.


Large self-insured companies are doing the same. Hannaford Supermarkets, a Maine-based grocery chain, has given its 9,000 insured employees the choice of having knee and hip replacements at National University Hospital in Singapore, where such procedures can cost a third of what they do in the United States. Hannaford waives all deductibles and covers travel expenses for the patient and a companion.

Other employers are offering workers cash incentives as high as $10,000 on top of free medical care and travel. It’s not hard to see why. Heart bypass surgery that can cost more than $100,000 in the U.S. is generally less than $10,000 in India’s finest hospitals, whose success rates rival those found in the U.S. and Europe, according to Josef Woodman, author of “Patients Beyond Borders,” a popular guide to medical travel.

So if healthcare in other countries is so good, why is it so cheap?

Experts point to a variety of factors. Doctors’ salaries and the cost of living are lower in many countries. Government-funded healthcare in some nations helps contain costs in private-sector hospitals, which don’t have to shoulder the unpaid bills of uninsured patients as U.S. hospitals do. In addition, malpractice insurance is cheaper and litigation awards are significantly smaller in most parts of the world.


That lighter liability burden is one reason hospitals in New Zealand can perform procedures such as hip and knee replacements for less than half the price some U.S. facilities charge. The Pacific island nation is wooing American patients by promoting its First World living standards and common language.

“We don’t have a tort system . . . [that’s] like winning the lottery,” said Steve Nichols, managing director of Medtral New Zealand, a medical travel company. “That reflects in the price.”

It’s also something consumers need to bear in mind in the event that something goes wrong. U.S. patients who believe they have been harmed can sue the foreign doctor or hospital -- but only in that nation’s courts.

Few people are likely to go through that kind of hassle, especially for a meager award. Texas resident Maggie Terry is still wearing the bandage from a $4,500 tummy tuck she got this spring at a small hospital in northern Mexico. The incision got severely infected and has yet to heal. Terry figures she’ll spend thousands more dollars with a U.S. plastic surgeon to repair damaged tissue.


“I wish I had never done it,” the 26-year-old said of her “bargain” surgery.

In Monterrey, officials at Christus know they have a long way to go to overcome Americans’ concerns about Mexico’s medical facilities, as well as stereotypes about the culture. This modern industrial city is home to some of Mexico’s leading companies and some of its wealthiest entrepreneurs. Familiar U.S. chains such as Starbucks and Chili’s abound.

Yet “Americans ask if we have cows and horses in the streets,” said Julio Cesar Lopez Dominguez, medical travel sales manager for Christus’ six Mexican hospitals, known collectively as Grupo Christus Muguerza.

To build consumer confidence, the company has obtained Joint Commission International accreditation for its High Specialty Hospital in Monterrey and has begun the process for its South General Hospital across town. An English-language website allows visitors to take a virtual tour of its facilities and read testimonials from American clients. Many come for laparoscopic obesity surgery, which at $9,000 is less than half the price charged by some U.S. hospitals.


While Christus’ medical travel business is still in its infancy -- it treated just 200 international patients last year -- it’s looking to grow that segment into one-third of its business within a decade.

How American doctors and hospitals respond to foreigners poaching their patients remains to be seen. Medical travel deprived domestic medical providers of about $16 billion in spending in 2007, according to Deloitte. That’s chump change in a $2.4-trillion healthcare system.

Some analysts believe that, at most, medical travel could shave a few percentage points off the overall healthcare tab for a typical self-insured company. That’s because a lot of the spending is for routine procedures that will never go offshore.

Still, a few thousand dollars here and there add up to real savings for any company. Deloitte figures that medical travelers will deprive U.S. providers of $373 billion in annual spending within a decade. Most of that will come from high-margin elective surgeries, which U.S. hospitals depend on for a good share of their profits.


Some are already feeling the pinch. Planet Hospital founder Rudy Rupak has added a handful of U.S. doctors to his network after they agreed to cut their prices.

“They’re savvy enough to realize that if they don’t get involved now they’re going to be struggling later,” he said.

U.S. providers that don’t wake up deserve to lose the business, said Tom Keesling, president of Raleigh, N.C.-based IndUShealth. The company arranges medical travel to India for individuals and large, self-insured U.S. firms.

Local hospitals “have been gouging corporations for years . . . saying, ‘You don’t have a choice. We’re a monopoly,’ ” Keesling said. “Well, guess what: Now we have global competition for healthcare.”






A dozen tips before you go

1. Check the foreign hospital’s accreditations or affiliations. Look for an institution approved by the Joint Commission International (, an affiliate of the Joint Commission, a respected, independent, nonprofit agency that accredits U.S. hospitals. Affiliations with well-known medical institutes are also a sign of quality.

2. Select a fully integrated hospital over a clinic when possible, preferably one that specializes in international patients. In the event of an emergency, everything you need will be under one roof.

3. Ask the hospital for data about quality indicators such as morbidity rate, staph infection rate and nurse-to-patient ratio. Find out how many procedures of your type have been performed there.


4. Make sure the doctor treating you is board certified, either in his or her own country or in a country with reputable medical care. Get the physician’s resume in advance and request references.

5. Insist on speaking with your doctor before treatment, just as if you were talking to your family physician at home. Ask questions until you are completely satisfied. Record the phone call or have someone other than you listening and taking notes.

6. Make sure the hospital staff speaks your language. Quick, clear communication is nonnegotiable.

7. Think about using a medical travel company. A good one can save you a lot of time by arranging appointments and telephone consultations, booking travel, helping you obtain passports and visas, transferring your medical records and arranging post-operative care. Find out whether you or the hospital is paying their fees. Get a detailed list of what is -- and is not -- included. Get everything in writing. Demand references. If the company doesn’t respond promptly to your initial request, move on. Even if you use a medical travel company, do your own due diligence on the doctors and hospitals the company recommends.


8. Take a companion with you -- and choose that person carefully. Your spouse or closest blood relative may not be your best advocate in a foreign country.

9. Don’t schedule your trip too tightly, and prepare to extend your stay. Get help with bill-paying, household chores, child and pet care, even powers of attorney, while you’re away.

10. Learn a bit about the country where you’re going. It will lessen your culture shock, and the locals will appreciate your interest.

11. Think hard about whether you want to combine medical treatment with leisure travel. Getting well should be your priority. And a vacation can eat up a lot of what you save on medical bills.


12. Even though price is the main driver for medical travel, don’t be penny-wise and pound foolish. Better to hire a top-flight surgeon on the front end than a malpractice lawyer afterward. Don’t skimp on lodging. Post-op recovery is tough enough without spending it in a fleabag motel. Think about flying first class.

SOURCES: Medical Tourism Corp.; “Patients Beyond Borders”; author Maggi Ann Grace; Times research