Cases & Commentaries

Round-Trip Service

Commentary By Mary H. McGrath, MD, MPH

The Case

A 70-year-old man with a long history of
degenerative joint disease was experiencing increased symptoms in
his left knee. He was referred by his primary care provider to an
orthopedic surgeon who recommended a total knee replacement. The
patient was eager for the surgery so he could return to his active
lifestyle, but the elective procedure couldn't be scheduled for a
couple of months. In addition to the delays with scheduling, the
patient also became concerned about the costs associated with the
surgery and his likely postoperative rehabilitation needs.

Based on a neighbor's recommendation, the patient
explored alternate options and ultimately had his total knee
replacement performed overseas. The surgery was scheduled within 2
weeks, at a fraction of the cost to the patient of domestic
surgery, and provided a very satisfying experience overall.
Approximately 2 weeks after the surgery, when the patient was back
home, he developed acute pain and swelling in his surgically
repaired knee. He contacted the US-based orthopedic surgeon who
originally saw him, explained the circumstances, and was told he
could not be seen because "we didn't perform the surgery, so you
should contact your operating surgeon." The patient was ultimately
seen in the emergency department and received appropriate treatment
for uncomplicated postoperative swelling.

The Commentary

The case presented has two improbable reasons
for the patient to travel to another country for his joint
replacement. If he lives in the United States, it is unlikely that
he would be subjected to a wait of several months or put on a queue
to wait for surgery, although that might be a cause for medical
travel in other industrialized nations. Second, his concern about
the cost of postoperative rehabilitation would not be mitigated by
traveling out of the country for surgery. In fact, problems with
obtaining postoperative rehabilitation services are more likely to
be exacerbated by medical travel. The outcome in the case also is
improbable. Sadly, after a major operation involving a complex
synthetic joint, it is unlikely that the difficulty is no more than
postoperative swelling to be addressed in one visit with no

These particulars aside, the
overwhelming advantage of joint replacement, or any medical
procedure, done overseas is that the operation is less
This advantage has led increasing numbers of Americans to obtain
overseas surgery, which makes the issue raised by this case
increasingly relevant.

This case highlights the issue of continuity
of care. Without arrangements for provision of postoperative care
by a surgical team familiar with the patient, the type of implant
used, technical aspects of the operation, perioperative infection
precautions, and early postoperative stabilization, it is difficult
to provide standard postoperative care. This patient developed a
postoperative problem, but even absent this, he needs a physician
to arrange and write orders for physical therapy to resume
weight-bearing activities and encourage mobilization of the

When consulted by a patient
returning to the United States with local wound problems 2 weeks
after surgery, the orthopedic surgeon's response is not simply
because he or she is miffed that the patient chose to obtain
surgery elsewhere. Rather, that surgeon is placed in a very
difficult position medically, ethically, legally, and financially.
He or she has no first-hand information about the procedure, such
as the quality of the tissue closed around the prosthesis or the
technique for attaching the ends of the device to the femur and
tibia. He or she may be unfamiliar with the specific device used (a
device that may or may not be approved for use in the United
States). If the situation looks problematic due to the possibility
of infection or excessive swelling, the patient may be facing
months of imaging studies, parenteral antibiotics, analgesics, and
therapy. For a patient with health insurance, this may or may not
be covered depending on whether the policy covers the costs of care
related to surgery that was not approved and covered initially. For
a patient who is underinsured or uninsured, these costs would have
to be paid out of pocket.

This last issue raises concerns
regarding liability exposure, since a patient with an adverse
outcome or a disappointing result, unable to pursue a successful
legal claim against an offshore provider, may associate the poor
outcome with the subsequent care provided in the United States.
Even if the case is uncomplicated, the US surgeon who initiates
postoperative care is agreeing to provide the long-term follow-up
that is needed to meet the standard of care. This means that if the
patient develops pain or mechanical problems with his knee
prosthesis in the future, the US surgeon would properly be
responsible for ongoing care by virtue of having functioned as
treating physician.

From a quality-of-care
perspective, the potential argument for offshore surgery would be
if the patient were unable to financially afford the operation here
in the United States. In this situation, the patient hopefully
would be aware of the need for adequate follow-up care and the
relative risk of complications with his procedure. The US surgeon
to whom he turns after his return would have an ethical obligation
to treat a life-threatening problem. Few would insist that that
surgeon is obliged to deliver non-emergent or long-term care for a
patient returning from surgery abroad. Similarly, if the patient
has health insurance, there is no consensus that US insurance
companies should have to cover follow-up care or costs associated
with complications in patients who elect to have surgery

The Big Picture: Medical
Tourism in Context

The roots of "medical tourism"
lie in the practice of a modest number of Americans who over the
years have had inexpensive cosmetic procedures while on vacation in
foreign countries. Today, the term is inadequate for the growing
health care phenomenon of "outsourcing" or "offshore

A consequence of escalating health care costs in
the United States, the global market for long-distance medical
services is expanding. Several operational models are already in
place. There is the outsourcing of hospital services such as
transcription, insurance processing, and information technology to
other countries with lower labor costs. Certain medical jobs are
also moving offshore as low-wage foreign providers offer deep
discounts on services like the real-time reading of
Offshore surgery is seen as an opportunity for low- and
middle-income Americans to have surgery for 20%-25% of the cost in
the United States, often with surgeons who are US trained, may be
US board-certified, and who may be working in hospitals that are
JCI (Joint Commission International) accredited.(3)

Growth in the global market is being driven by
the complex and costly needs of an aging population, an increasing
number of uninsured, the high cost of health care for US companies,
referrals by US corporations and insurance companies, and
aggressive marketing by hospitals in countries like India and
Malaysia. With the building pressure for outsourcing surgical care,
many questions are raised. These include quality and safety, the
ability to assess competence, and the question of who will bear the
responsibility for postoperative follow-up care. Other fundamental
issues are legal redress, medicine's relationship with big
business, potential erosion of the American health industry by
foreign competition, and consequences for the US surgical
workforce. Another debatable element of offshore surgery is the
access overseas to services, organs, devices, and technologies
still in clinical trials or unavailable in the United States due to
regulatory constraints.(4)

The surgical procedures that lend themselves to
offshore care are non-urgent, short-duration treatments that are
expensive in the United States and appropriate for patients with
less severe conditions.(5)
Orthopedic joint replacement surgery, some cardiac surgery,
weight-loss surgery, cosmetic plastic surgery, dental surgery, and
infertility treatments are those most frequently offered by the
offshore hospitals seeking US patients and offering lower
prices.(6) The
countries able to offer these values are developing nations that do
not have the drivers that make American health care so expensive:
cost of labor, cost of equipment and facilities, and the cost of
pharmaceuticals and devices. The financial differences can be
dramatic. For a hip replacement that might cost $32,000 in an
American hospital, the cost would be $9000 in India. A cardiac
bypass costing $100,000 in the United States costs about $12,000 in

With lower cost as the primary reason for medical
travel, until recently most American participants have been
uninsured or underinsured people trying to cope with large
out-of-pocket costs.(8) A
relatively limited group, the number of individuals obtaining
surgery under these circumstances is thought to have been 500,000
in 2009. This may change, however, as US health care insurers and
large employers look at the savings they could enjoy by providing a
mechanism for their members or employees to travel for
Promoted and facilitated by a burgeoning industry supporting
medical travel, the logistics may become more manageable and the
numbers of participants could increase rapidly. At this point,
there are no solid estimates, but most economists predict a
many-fold increase in medical travel over the next 10
The unknowns include the impact of health care reform in the United
States in terms of the number of uninsured, limitations on covered
benefits, and the regulation of the health insurance industry.

This patient's experience
illustrates several key points for those considering or advising
others about medical travel:

  • For patients without health insurance,
    the need for follow-up care must be calculated in the cost of the
  • For patients with health insurance, the
    insurer's policies about coverage of postoperative care need to be
    clear before proceeding.
  • Even for straightforward interventions
    such as dental work or minimally invasive cosmetic surgery,
    follow-up is needed and complications can occur. For more complex
    procedures such as weight loss surgery, measures such as lap band
    adjustment are commensurately more complex and spread out over
  • Patients who travel for advanced medical
    procedures available overseas but not adopted by US surgeons
    pending outcome studies and clinical trials should seek expert
    advice before going forward with these interventions.
  • Any health insurer sending patients to a
    foreign country for surgery should guarantee that US-based
    follow-up care is available, require credentialing and assessment
    of the providers in the foreign country comparable to that in the
    United States, and ensure that patients have the same appeal and
    legal rights as they would in the United States.
  • Entities accrediting offshore facilities
    should consider the establishment of measures to ensure continuity
    of care and longitudinal care as necessary components of a safe

From a policy perspective,
offshore surgery has been described as a market correction for
runaway health care costs in the United States. Some postulate that
it may force the health care industry in the United States to make
the changes necessary to render health care affordable. While a
popular argument, the types of procedures appropriate for medical
travel (non-urgent, short-duration, costly, suitable for healthier
patients capable of air travel) account for less than 2% of US
spending on health care. Moreover, from an operational standpoint,
implementation of organized overseas programs will skim off from a
US hospital the most lucrative interventions with the best results,
a practice unlikely to improve its bottom line.

The most pressing task for
the American medical community is the education of patients who
choose to travel abroad for medical care. Patients need to be
informed that complications occur in a predictable number of
interventions under any circumstances, that devices and treatments
available outside the United States may not be subject to rigorous
scrutiny, and, most importantly, that a surgical procedure is not
an isolated event. The US health care system recognizes this with
global surgical fees that include up to 4 months of postoperative
care. This, of course, contributes to the costs that make US health
care more expensive than offshore care.

Mary H. McGrath, MD,
Professor of Surgery, Division of Plastic Surgery

University of California,
San Francisco


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