Medical Outsourcing

[wanderer69]

Written from the advisor perspective:

FPA Journal - Medical Outsourcing: Reducing Clients’ Health Care Risks

 

[FinanceGeek]

Interesting that for all the initials after the authors' names, MD was not one of them.

We're coming to the time when the planeloads of sick people will go in both directions, foreigners with money seeking leading edge health care at top US clinics such as Mayo/Cleveland, and Americans without good insurance going abroad for cost savings. Well, its bullish for the airlines at least!

I guess attorney will be the last bastion of outsourcing free employment. It sure helps that attorneys can laws preventing it.

 

[Michael]

According to the article, 500,000 Americans went overseas for treatment last year, and the number is rapidly rising. Why not just let foreign hospitals set up branches here, and staff them with foreign trained staff? Demand for a their less expensive product obviously exists. If Toyota can set up operation here, why not Bumrungrad or Apollo hospitals?What am I missing?

 

[Rich_by_the_Bay]

Why not just let foreign hospitals set up branches here, and staff them with foreign trained staff? Demand for a their less expensive product obviously exists. If Toyota can set up operation here, why not Bumrungrad or Apollo hospitals?What am I missing?

I think it's about the costs. You can't just build a building and hire foreign doctors: the would be subject to the same legal requirements, liability insurance, discounts, incentives, maintenance costs. contracts with big insurers, accreditation, obligation to serve the underinsured, etc. Doctors salaries account for a surprisingly low percentage of overall health care cost.

It's the so-called system that makes things so costly, regardless of where you ship in the providers from. I like the idea of a hospital abroad whose quality and standards were vetted by American agencies or renowned medical schools. At least for common surgical procedures, it might make good sense once properly studied for safety.

 

[Michael]

Thanks Rich. I will give some thought to the system, and to the accrediting issues mentioned in the article.

 

[ERD50]

It was my understanding that some of these places are set up very 'assembly line' fashion. And I mean the good part of assembly-line, focus on a specific operation, everything set up for that operation, division of labor, quality control with quick feedback, etc, etc, etc

So, to Rich's questions about cost, I wonder if some of that could be transplanted to the States? Maybe my impression is wrong, but I don't think very many doctors here are so focused on specific operations, they get involved in many areas.

John Stossel did a report on Health Care a few weeks back, I only saw a portion of it. He claimed that the Lasik-type eye surgeries are becoming very competitive and working quite different from what we see with more traditional care. His explanation was that insurance companies rarely cover this operation anymore, so the businesses have become much more customer focused. Price lists up front, accommodating hours, etc, etc, etc. I don't know if that was mostly hype/dramatization or not, but a quick google of an overseas medical site said that Lasik can usually be done in your home country at competitive prices. But a long list of other operations and dental care offered. Coincidence?

Is there something to that?

-ERD50

 

[chinaco]

Some insurance companies are getting on board with foreign treatment. I suspect it will become a normal option on insurance in the next 10 years if a national program is not created.... It might anyway.

Interesting note: DW and I have LTC insurance through her group plan at work. The original insurer is exiting the market. There is a replacement insurer. We have the option to transfer our policy into the new group plan with the new insurer. We will do so for a number of reasons (I will not elaborate here)... The new plan offers international LTC. The rate is reduced to 75% of stateside benefits. But I think this is an emerging trend that will continue.

 

[Rich_by_the_Bay]

So, to Rich's questions about cost, I wonder if some of that could be transplanted to the States? Maybe my impression is wrong, but I don't think very many doctors here are so focused on specific operations, they get involved in many areas.

Yes, I think there is merit in that, and we are seeing it applied in selected situations. First, in patient safety (a great place to start) and quality control. Some procedures lend themselves to that type of approach.

But nonsurgical (and many surgical) scenarios are simply too amorphous and variable. For example, if I admit you with pneumonia and you have diabetes, your initial treatment would follow well-established guidelines for care. But 2 days later, your insulin regimen might change, your cultures might show resistant bacteria and you might develop antibiotic side effects. When I'm ready to send you home, your insurance company might refuse to cover home oxygen, or require another day to set it up. The morning of discharge, your sugar might go too low because you missed breakfast - add another day, and now your spouse is unable to take you home because she was scheduled to be out of town all day (big deal at work, can't cancel).

A contrived example, but just to illustrate how a typical admission might go -- hard to automate.

 

[ERD50]

Yes, I think there is merit in that, and we are seeing it applied in selected situations. First, in patient safety (a great place to start) and quality control. Some procedures lend themselves to that type of approach.

For example, if I admit you with pneumonia and you have diabetes, ....

A contrived example, but just to illustrate how a typical admission might go -- hard to automate.

Yes, understood Rich. There is no way the 'assembly line' approach is going to replace general care, too many variables.

But, I've always had the impression that these overseas places are 'cherry-picking' the operations. Taking specific procedures that lend themselves to these methods.

Actually, an oral surgeon probably isn't far from this concept. At least from my experience - the dentist refers you to the surgeon, you get an interview and review, and on the day of surgery (wisdom tooth extraction as an example), he his handling multiple patients in an almost assembly line process. So yes, it would be limited to the procedures that are best suited for it, maybe expanded over time and experience.

Maybe an analogy from my own industry experience fits: The assembly of electronic products became very, very automated, but repairs were still a 'craft-person' type job - each unit checked by hand, analysis and decisions made, and the repairs often done by hand. But, if we had detected a common defect in a large group of products ( a defective batch of parts slipped into the assembly line for example), well, we set up an assembly line process to rework those units.

-ERD50

 

[Rich_by_the_Bay]

But, I've always had the impression that these overseas places are 'cherry-picking' the operations. Taking specific procedures that lend themselves to these methods.

Agree completely.

Routine procedures can be highly systematized with good efficiency, as long as there are provisions for the inevitable delays, emergencies, late arrivals, etc. In fact, I would guess that quality would improve.

At my institution a patient can receive sedation, colonoscopy, and endoscopy of the stomach and esophagus in 45 minutes door to door. Another 15 min or so in the patient lounge to finish waking up and figure an hour all together.

I'm happy if I can get out of my dentist's office that fast.

 

[Billy]

FinanceGeek

foreigners with money seeking leading edge health care at top US clinics such as Mayo/Cleveland, and Americans without good insurance going abroad for cost savings.

Foreigners with money also go to these ‘premier medical destinations’ such as Bumrungrad, et al. The US isn’t the only choice anymore. I see this as a good thing. Competition is good for the markets.
RichinTampa

It's the so-called system that makes things so costly, regardless of where you ship in the providers from.

I agree completely, Rich. It’s not so much the quality of the care itself, but the system that wraps itself around the providing of that care.

I like the idea of a hospital abroad whose quality and standards were vetted by American agencies or renowned medical schools. At least for common surgical procedures, it might make good sense once properly studied for safety.

It makes sense now. If you ever get to this side of the globe, you might really enjoy touring these hospitals and clinics. With your professional background as a basis from which to make an informed analysis, I would be most interested in your view.

ERD50

His explanation was that insurance companies rarely cover this operation anymore, so the businesses have become much more customer focused. Price lists up front, accommodating hours, etc, etc, etc.

This has been our position all along. When the costs of a procedure are left to the open market, prices drop. Competition comes in and the consumer benefits.

Chinaco:

Some insurance companies are getting on board with foreign treatment. I suspect it will become a normal option on insurance in the next 10 years if a national program is not created.... It might anyway.

Last time we were in BKK airport waiting for our connection to Phuket, we met up with a man working for Bumrungrad who was working on an ‘insurance deal’ with the US labor unions for medical outsourcing. This was to help companies such as GM whose medical costs for retired employees have put such a crimp into their bottom lines.

It might seem very awkward and unbelievable now, but like you say, it could very well become more common place in the future.

I believe the US is losing its edge on the providing of medical care because it is being entrapped by all this talk of universal care and the ‘right‘ to health insurance. Perhaps it is a necessary first step. It is my hope that another, more viable solution will come up.

Yes, I know, there are lots of people who disagree with me. But consider the following. prices listed in Thai baht. Simply divide by 34:
News 20/9/2007
Special Promotion "Sep-Oct"
Bangkok Heart Hospital

• Basic Heart Check-up from 8,915 to 4,450
• Healthy Heart Check-up from 13,815 to 8,290
• Executive Heart Check-up from 27,515 to 16,500
• Diamond Heart Check-up from 49,315 to 29,500
• 64- Slice CT Scan package 13,900
• CAG package 39,000 (conditions applied)
• CABG package 480,000 (conditions applied)

Dental

• Brite smile Tooth Whitening from 18,000 to 15,000
• Dental Implant (Branemark) from 88,000 to 80,000
• Dental Implant (Replace and ITI) from 80,000 to 75,000
• Laser Tooth Whitening (with Home Bleaching 4 sets) from 19,000 to 14,000

For other alternative health sites see http://www.retireearlylifestyle.com/links_medical_options.htm
Be well,
Akaisha
Author, The Adventurer’s Guide to Early Retirement

 

[chinaco]

If the medical facilities develop a reputation for quality... they could become a preferred destination instead of just a lower cost alternative.

But for now, basic economics are at work. Costs have hit a level where people and businesses are seeking alternatives.


The good thing about this is that competition is usually the stimulus that brings costs down. Plus, there is a fixed capacity in the US... If demand exceeds capacity, then prices go up.


Medical outsourcing seem viable to me. Matter of fact. I am surprised that Mexico does not have 4 or 5 major medical clinics just across the border form the US. They could specialize in certain procedures and dominate the US market for medical outsourcing in those areas because of their location. But they would need to be competitive with Thailand and India.

 

[Billy]

I am surprised that Mexico does not have 4 or 5 major medical clinics just across the border form the US. They could specialize in certain procedures and dominate the US market for medical outsourcing in those areas because of their location. But they would need to be competitive with Thailand and India.

One such location is Sanoviv: Sanoviv Integrative Health Care - Home.

They offer a blend of medical care that includes the Western approach and nutrition. I know that US insurance covers much of their services, but I don't know how competitive they are...

Be well,

Akaisha
Author, The Adventurer's Guide to Early Retirement

 

[unclemick]

Sooo - to paraphrase Cool Hand Luke - What we have here is a cross between Freidman's World is Flat and the late Deming's Red Bead Experiment with the Internet as our advertising medium.

eh?

Er ah - at my 14th year of ER and within spitting distance of Medicare - I still believe staying healthy is the best revenge.

Phys ed, eat those nuts and twigs and ah la the Bear - stay agile, mobile, and hosile - oh yeah always wear your seatbelt.

heh heh heh - I did renew my Passport. Prudence being that across the river is Kansas!

 

[Michael]

So the general consensus seems to be that there is no realistic way to reform the US system so as to make medicine that is affordable to the middle class available here. The only options being left open to the middle class are to go overseas, or support national health care. I'll have to give some more thought to the implications of this trend.

 

[Rich_by_the_Bay]

So the general consensus seems to be that there is no realistic way to reform the US system so as to make medicine that is affordable to the middle class available here. The only options being left open to the middle class are to go overseas, or support national health care. I'll have to give some more thought to the implications of this trend.

Don't confuse universal coverage with national health care. I support the former.

 

[Michael]

Okay, I see the difference. That seems to be the way poll leader Hillary is trending. Open up the federal programs to everyone, and mandate that everyone buy coverage if they don't already have it.

 

[Rich_by_the_Bay]

Okay, I see the difference. That seems to be the way poll leader Hillary is trending. Open up the federal programs to everyone, and mandate that everyone buy coverage if they don't already have it.

Yes, whether one approves of some of Hilary's other beliefs and politics or not, she seems to have learned a lot from her first health care reimbursement debacle. Her latest statements are closer to Mitt Romney's plans for Massachusetts than to 'socialized medicine."

Seems to me that almost everyone, conservative to liberal, agrees that some kind of substantial reform is needed, both from a business and social perspective.

 

[FinanceGeek]

Don't confuse universal coverage with national health care. I support the former.

OK, I understand the difference in the words you wrote, but I am not understanding how the implementation would actually differ. Can we really have universal coverage while avoiding a large and cumbersome government program to administer it (the European and Canadian answer appears to be "no"). Is the model mandating auto insurance? That doesn't work well in states where insurers are forced to have universal rating, I don't see how health care insurance mandates would work out differently.

 

[Rich_by_the_Bay]

OK, I understand the difference in the words you wrote, but I am not understanding how the implementation would actually differ. Can we really have universal coverage while avoiding a large and cumbersome government program to administer it (the European and Canadian answer appears to be "no")

Not sure.

About the only thing most agree on is that the current scenario is highly, highly dysfunctional for almost everyone but the wealthy and the insurance carriers. High costs, mediocre quality in many cases, 30% administrative overhead, decreasing physician incomes. Retirements are postponed and career changes and entrepreneurial efforts are stymied by inability to get affordable (or any) insurance. Large employers are gasping to remain competitive due to health care. Emergency rooms and hospitals are overburdened with the un- and underinsured, and guess who pays in the end...

I don't consider myself a bleeding heart, but I know what health care is all about and what we have is not good enough. If having a larger government/tax component is what it takes (short of some sort of Machiavellian socialized medicine scenario), I'm read to consider it. In fact, socialized medicine (as in Scandinavia and France, for example) are not sounding nearly as bad as they once did.

But hopefully we can find a privately based, government-defined universal coverage system for everyone, with a safety net type national health care for those who can't afford otherwise. Just my opinion from the trenches.

 

[Billy]

Michael

The only options being left open to the middle class are to go overseas, or support national health care. I'll have to give some more thought to the implications of this trend

When we are left with “either-or’s” we are not being creative enough in our options.

Open up the federal programs to everyone, and mandate that everyone buy coverage if they don't already have it.

How can you ‘mandate’ that everyone buy health insurance? There will always be people who will choose to to be covered by US health insurances..
Rich_In_Tampa

Seems to me that almost everyone, conservative to liberal, agrees that some kind of substantial reform is needed, both from a business and social perspective.

Yes, we all agree the system is broken. It’s how to ‘fix’ or manage that system is where the arguments/discussions begin.

About the only thing most agree on is that the current scenario is highly, highly dysfunctional for almost everyone but the wealthy and the insurance carriers. High costs, mediocre quality in many cases, 30% administrative overhead, decreasing physician incomes. Retirements are postponed and career changes and entrepreneurial efforts are stymied by inability to get affordable (or any) insurance. Large employers are gasping to remain competitive due to health care. Emergency rooms and hospitals are overburdened with the un- and underinsured, and guess who pays in the end...

These are all reasons to have the system be opened up to the free markets. This is how prices are brought down and will benefit the consumer.
30% administrative overhead is because of all the paperwork that the insurance companies and lawyers et al require. The paperwork is required so the ‘right’ people will pay the (guaranteed) payment.

Employers shouldn’t’ have to gasp to remain competitive because of health care packages. I don’t believe employers should be required to give these health care packages. What if the employees were taxed on the value of that benefit? They would go shopping for a better deal, or refuse the employer provided health package. There are other options.

High cost and mediocre quality means that the open market hasn’t been allowed to come in and clean out the dregs of the system.

In fact, socialized medicine (as in Scandinavia and France, for example) are not sounding nearly as bad as they once did.

France also virtually has guaranteed jobs there too, something I find appalling. I would not hold France up as a model for our nation. (OMG)

Yes, I have heard their health care is decent. But that country has a myriad of problems in most other areas. Many of which I would not want in the U.S.

Be well,
Akaisha
Author, The Adventurer’s Guide to Early Retirement

 

[Billy]

Here's the latest on changes in Healthcare in France:

British retirees in France lose free health care
By Peter Allen in Paris

http://www.telegraph.co.uk/news/main.jhtml?xml=/news/2007/09/03/wsarko103.xml

So I guess that still leaves Scandinavia ... Be sure to take a jacket!

Humorously,
Akaisha
Author, The Adventurer's Guide to Early Retirement

 

[chinaco]

OK, I understand the difference in the words you wrote, but I am not understanding how the implementation would actually differ. Can we really have universal coverage while avoiding a large and cumbersome government program to administer it (the European and Canadian answer appears to be "no"). Is the model mandating auto insurance? That doesn't work well in states where insurers are forced to have universal rating, I don't see how health care insurance mandates would work out differently.

I believe we can. Pass a law. No red lining (or rating) of someone that has a health problem (period) same cost for everyone. Mandated coverage. A couple of defined standard coverage plan (that represents a minimum plan for the mandate).... But more is available if wanted (insurance companies can get creative). Bottom-line tax write-off for individuals on premium. $ for $ on tax owed not wages received. This could be implemented several ways.

I will admit, there are a few practical problems that need to be worked out... but it can work. Make the payments via payroll deduction like taxes. Bottom-line, people at the bottom are on welfare or paid for by cost shifting. They will probably be paid for by the Govt. The Govt can negotiate an HMO style plan for poor people. It is typically the cheapest approach and good enough.

Dealing with those that do not comply will be a sticky issue... but enough thought will solve that problem. Garnish their wages. The point is to make it affordable. The plan should be set it up so people can typically afford it. If they cannot afford it, they wind up in the HMO style plan. If someone can afford it and does not pay... Put the squeeze on them. If they do not die... they will be fined and have their wages garnished. Let the government collect that money along with the taxes and pay the insurer for the delinquent. Bottom line, there will alway be some holdouts just like with taxes. But most will comply.

What we have right now is each insurance company trying to increase their individual company's profits in a marginal way by excluding certain people.

 

[FinanceGeek]

Thanks Chinaco. If uprating were disallowed, or perhaps limited to a narrow band that was age, state, or health factor related, that would surely be better for those who cannot be underwritten now.

But wouldn't we create a situation like car insurance in MA or NJ where rates are set by the state regulatory process (rather than underwriting experience), and it winds up being terribly expensive for everyone? Yes you are guaranteed you can buy health insurance, but the premium is $10k/month. Oh, and by the way its mandatory that you buy this or go to jail.

I guess the advantage of such a system is that everyone COULD buy insurance and it would be a system of issuing tax breaks, vouchers, etc. based on income/wealth to guarantee universal access.

I still wonder as you do about enforcement. Many (including I suspect many of today's uninsured) aren't filing tax returns or working in garnish-able (is that a word?) jobs. How to reach them?

 

[chinaco]

FG

You probably are correct... there might be some unintended consequences, and possible difficulties. IMHO Some attempt to implement a affordable privately run system seems preferable to a government run system.

There will probably need to be some regulation on the insurance industry... But I suspect that they will make a reasonable profit. Probably a majority of the uninsured are not high risk... they just cannot afford the premium. Expanding the pool should not upset the overall equilibrium of group plans. It makes sense to craft the program to include mechanisms that would motivate people to conserve (i.e., not waste). Copays seem to work reasonably well.

We will always have some number of people that will not conform. I am not sure that sending them to jail is the answer. But, fines and other pressure would cause most to conform. Put it like this... people that have little stake in society will probably be on welfare and/or not working anyway. Some sort HMO model would be their option.