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3 posts categorized "Medical Tourism"

June 02, 2009

Grand Rounds Vol. 5, No. 37: The June Is Bustin' Out All Over Edition

June is bustin' out all over . . . .  Lord knows my nose knows it, thanks to all the pollen in the air these days.  Check out the classic movie rendition of this set piece (well worth the eight-minute investment), let your coffee and/or antihistamines kick in, and then let's dive into the past week's medblogging, loosely categorized into insights of patient bloggers, provider bloggers, bloggers I've met in real life (the number keeps growing), bloggers following the money trail through the health care thicket, and bloggers who are or should be dancing and/or shirtless (watch the whole movie clip . . . on second thought, let's leave it at dancing).


Last time I hosted Grand Rounds, we delved into the origins of Valentine's Day, so even though we're a couple weeks shy of the vernal equinox, since June is bustin' out all over, the historian in me feels the need to touch on an ur-Spring nugget or two before we get going.  Where do these celebrations of Spring come from?

Attis was a Phrygian god, whose annual death and resurrection were mourned and celebrated at a Spring festival.  (On the other hand, the death and rebirth of the Sumerian Tammuz was a summer solstice thing rather than a vernal equinox thing.)  James Fraser, in The Golden Bough, wrote:

The annual death and revival of vegetation is a conception which readily presents itself to men in every stage of savagery and civilisation: and the vastness of the scale on which this ever-recurring decay and regeneration takes place, together with man's most intimate dependence on it for subsistence, combine to render it the most impressive annual occurrence in nature, at least within the temperate zones. It is no wonder that a phenomenon so important, so striking, and so universal should, by suggesting similar ideas, have given rise to similar rites in many lands.

What I best remember from The Golden Bough, though, is the tale of the king-for-a-year, who ascends the throne as a result of a cultic regicide, and ends his term the same way.  Great stuff.

For further reading linking The Golden Bough, The Holy Grail, Wagner's Parsifal, and T.S. Eliot's The Waste Land, check out Derrick Everett's article on The Waste Land.

I'm not certain that Rogers and Hammerstein had these themes in mind when writing Carousel.  Heck, who knows what they had in mind; they threw in a happy ending that wasn't in their source material (but hey, that's show business).  You, dear reader, certainly didn't have these themes in mind when you tuned in to today's edition of Grand Rounds.  Nevertheless, on with today's show.

Provider Bloggers

At Musings of a Distractible Mind, Dr. Rob discusses Atul Gawande's recent New Yorker piece on health care cost variations across the country (a good read, well worth the time), which focuses on McAllen, TX, a small border town that consumes far more than the average annual per capita amount of health care services.  Gawande loops in the Dartmouth Health Atlas folks, asks the hard questions about physician-owned facilities and financial incentives, and concludes that outfits like Geisinger, Intermountain, Kaiser Permanente and Mayo -- not-for-profit integrated delivery systems with salaried docs -- have the model we should strive to emulate systemwide.  Dr. Rob recounts his own experience with physician-owned facilities.  His conclusion is a folksy twist on Gawande's:

How do we fix it?  There are lots of good answers, and lots of dumb ones as well.  The bottom line is the bottom line, though.  How you pay docs will determine what happens.  It’s America, after all.  It’s what makes us great.  Right?

Right.  The thing is, guys, we've known this for at least forty years.

ACP Hospitalist reports on Sid Wolfe's new Public Citizen campaign to get hospitals to step up reporting of physician wrongdoing.  Bob Wachter, at Wachter's World, delves deeper into the problem, and says:

I’m proud to say that over the past five years, my hospital (UCSF Medical Center) has taken Leape’s challenge to heart, withdrawing clinical privileges (and filing accompanying NPDB reports) in several cases for behavior that, I’m quite confident, would have been tolerated a decade ago. This is progress. As Kissinger once said, “weakness is provocative.” As more hospitals take this tougher stance, I think we’ll see the boundaries of acceptable behavior shift everywhere. And patients will be safer for it.

Bongi, at other things amanzi, recalls a suboptimal experience in his training, when the "see one, do one, teach one" approach was reduced to "read an article about one, do one immediately afterwards."

At Providentia, Romeo Vitelli looks at the historical precursors to Jenny McCarthy and the current crop of anti-vaccinationists. 

Ken Cohn, a physician and consultant
(who I know in real life [IRL]), recounts a (positive) experience in asking health care administrators to consider ethics in physician-hospital relationships.

I take a baby aspirin a day, and Doc Gurley says I should keep on doing so, because I'm better off puking up blood than having a heart attack.

Seizures and how they have been misunderstood (epilepsy vs. demonic possession) is the subject of this week's selection from Mind, Soul and Body.

Suddenly becoming a first responder at 35,000 feet? On Your Meds' Barbara Olson takes you there.  (The blog is part of Medscape, so free registration is required).

NurseAusmed recounts difficulties in handling patient communications and managing patient expectations at Nursing Handover.

How to Cope With Pain takes a page from a book offering guidance to those who have lost their spiritual way and turns the advice to use for those facing physical, rather than spiritual, pain.

Web 2.0 meets the health care establishment, and KevinMD [IRL] observes that since health care is largely a business, this should not be surprising.  For a window into social media use by health care provider organizations, check out healthsocmed.

The anonymous author of Notes of an Anesthesoboist says it's hard for women doctors to make friends . . . perhaps they should introduce themselves as drug pushers instead?

John Crippen wants to, but the NHS Blog Doctor just can't look away from the kids pushed onto TV talent shows by 21st century stage mothers.

Paul Levy [IRL] goes another round with SEIU Local 1199 at Running a Hospital.

At UDM Solutions, David Siwicki provides a clinical perspective on deciding whether to prescribe opioids for chronic pain patients who use marijuana.

Nancy Brown offers sound advice on talking to teens about alcohol at Healthline's Teen Health 411.

Follow the Money

DrRich, at the Covert Rationing Blog, always follows the money, and this week the trail leads to the following unlikely destination: the American College of Surgeons encouraging malpractice suits -- against overseas surgeons offering services to medical tourists.

Big Pharma also always follows the money, and David Williams, at the Health Business Blog, remains perplexed over Pharma's failure to engage with the public via twitter.  (GSK has already responded to David's post, but in a way that doesn't exactly undercut his point.)  For a window into Pharma's engagement with social media, look no further than Shwen Gwee, who organized the Social Pharmer unconference in conjunction with the HealthCamp Boston unconference I co-organized in late April.  Speaking of social media, feel free to follow me on twitter: @healthblawg.  

Last week, I took a look at the proposed Medicare Inpatient Prospective Payment System (IPPS) updates for FFY 2010.  Among other things in the rule (including payments cut to the bone), I was surprised to see tucked away in there a tacit acknowledgement that the whole "no pay for never events" thing isn't really saving anybody that much money.

Lots of hospitals are touting new private rooms these days.  Seems to help patient care (lower infection rates, better sleep, more privacy), but despite the benefits, Jeffrey Seguritan at nuts for healthcare observes that the private room is being pushed by the AIA, and wonders whether health care dollars really ought to be spent these days on capital projects such as these.  (My brief response: these days, they really aren't, given the tight financial markets).

In a medblogosphere first, The Happy Hospitalist has publicly described an entry in the $10 million X Prize competition:

How do you [reduce health care costs dramatically]?  Here's my theory.  You can do more to affect health care costs by getting 10,000 people to change their lifestyle habits than you can by getting a few hundred docs to change how they document and collect data and prescribe some pills.

So here's what you do.  You bribe the public.  People are inherently lazy, but they respond well to piles of money.

For a fuller introduction to the X Prize competition: Scott Shreve [IRL] posted his twitterview on the X Prize with Bertalan Mesko (@berci) at Crossover Health Learn more about it there.

The big HITECH Act pot of money that everyone in health IT is itching to get their hands on is going to have some strings attached: chief among them are going to be definitions of "meaningful use" and "certified EHR."  Them that are likely to be certifying -- CCHIT -- have been the target of some possibly well-deserved pot-shots, and the gloves have come off.  See Gilles Frydman's [almost met IRL at the Health 2.0 conference in Boston a month or so ago] framing of the debate at and John Moore's [IRL] take at Chilmark Research.  

Health technology research and development yielded two bits of news this week: FDA approval of a handheld ultrasound unit, via Vijay Sadasivam's scan man's notes, and Ves Dimov's post at Clinical Cases and Images on the Rovio - a WiFi-enabled mobile webcam, which may be more attractive to medical users given the recent study that found patient satisfaction, physician satisfaction and diagnostic agreement (measured both between face-to-face and virtual vists, and between two face-to-face visits) to be similar for face-to-face and virtual visits.  (Yesterday's Boston Globe took a closer look at this study, virtual visits in general, and American Well in particular.)    

The health IT crowd is working on interoperability and portability of health information.  Google Health is one of the platforms that may enable folks to reach this holy grail.  Brian Dolan at mobihealthnews says that Google Wave, an open-source tool for communication and collaboration, looks like a killer tool for enabling Google Health to do more in terms of provider-provider and patient-provider collaboration.

Evan Falchuk's observation at See First on prevention: it ain't cheap; treatment of preventable disease is more expensive than the savings from avoided disease and complications, so we need to be talking about more than cost-effectiveness.  [Supposed to meet IRL soon.]

Patient Bloggers

For some reason, diabetics are very well-represented among Grand Rounds' usual suspects.  This week, they're turning into media critics as well, following President Obama's nomination of Sonia Sotomayor to the Supremes.  Amy Tenderich [who I also almost met IRL at Health 2.0] touched on the media frenzy regarding the nominee's Type 1 diabetes at The Diabetes Mine, as did Six Until Me's Kerri Morrone Sparling.  Not to leave Type 2 diabetes unattended, Rachel Baumgartel offers tips for the newly diagnosed Type 2 diabetic at Diabetes Daily.  (For those who care to immerse themselves in The Politics of the Sotomayor Nomination, the good folks at SCOTUSblog say come on in, the water is fine.)  For a taste of the difficulties faced by some diabetics traveling through airports with needles and curious liquids, head on over to Tim Brown's post at Shoot Up or Put Up

At Getting Closer to Myself, Leslie offers her reflections as a twentysomething with auto-immune disease, specifically a feeling of how she can't go home again to an idealized summer retreat.

Barbara Kivowitz describes a good day at In Sickness and In Health, and invites all of us to do the same.

Bloggers Who Are or Should Be Dancing

Val Jones [IRL] is pretty pleased with her high-deductible health plan (HDHP) - cash-only PCP combo.  I hope her husband is dancing after the office procedure scheduled on a dime last weekend . . . and I hope Dr. Val has all the releases for those photos stashed away somewhere.  It's a good solution for those with no chronic conditions, young kids, or other sources of regular interactions with the medical-industrial complex.  And no less a luminary than Clay Christensen says we're 5-6 years away from the tipping point (to mix metaphors) on HSA/HDHP combos, at which time we're likely to see a significant change in the economics of healthcare (with or without significant movement in DC).  For one example of where this may play out, see my recent post on retail health clinics.

No dancing for you if you're susceptible to one of the side effects of Cipro and its relatives (fluoroquinolones): tendon rupture.  There's a black-box warning regarding this, but many clinicians and patients are unaware, says Paul Auerbach at Healthline's Medicine for the Outdoors.

InsureBlog's Bob Vineyard shares good news for Cuba's pre-op transsexual population: coverage is here.  Surely cause for someone (patients, if not bloggers) to dance.

Well, that's the last dance . . . for this week.  See you around the medblogosphere, and next week at the next edition of Grand Rounds

David Harlow
The Harlow Group LLC
Health Care Law and Consulting

March 19, 2009

Health Wonk Review: Spring has just about sprung

Michaels S C Welcome to Health Wonk Review, where everyone is above average.  We enjoy above-average health care costs per capita, above-average uninsured rates, and above-average obsession with health care reform.  That's what it's like today in America.  Our president has said, Change has come to America.  In the words of Robert Hayden's [American Journal]:

america     as much a problem in metaphysics as
it is a nation earthly entity an iota in our
galaxy     an organism that changes even as i
examine it     fact and fantasy never twice the
same     so many variables

Like Schrodinger's cat, America's health care system seems to change in the changing light as we examine it; one thing we can all agree on is that it needs some work. 

Franz Kline Steve Martin We begin with some broad brush strokes on form and amount of spending:

Len Nichols presents HEALTH REFORM: Moving Past the Impasse on the Public Plan | New America Blogs posted at New Health Dialogue

Maggie Mahar presents Health Beat: Thinking About Dr. Atul Gawande’s Congressional Testimony Part 1: Why Health Care Reform Will Require Additional Spending at Health Beat.

Lewis Hine Mechanic One cost, no matter what the payment system, is labor.  Lynn Nicholas, President of the Massachusetts Hospital Association writes about some pending changes to labor laws that might make it easier for labor to unionize, presenting the favored position of a non-union shop as one of worker, rather than employer, preference.  See Keeping Communication Lines Open in the Healthcare Labor Debate at CommonHealth, the Massachusetts health care reform blog of WBUR (a Boston NPR affiliate).

Who Will Pay for Prescription Drugs? asks Adam Fein at Drug Channels. CMS projections show that the government will have a very strong hand in managing retail drug spending and shaping the future of drug channels.  How will that affect pricing and R&D?  Richard Fogoros (DrRich) presents A Brilliant Plan For Preserving Pharmaceutical Progress at The Covert Rationing Blog, saying, The title says it all. Can we have our cake (drug price controls) and eat it too (continue drug innovation)? DrRich says, yes we can!  Check out his proposal.

Pills My dad used to say he wanted to listen to a radio station that broadcast only good news (not Good News, just good news).  Merrill Goozner, of GoozNews, suggests this week that there ought to be a journal dedicated solely to publishing negative results -- as soon as they're known -- as he is all hopped up due to delayed publication and/or suppression of data on adverse effects of drugs.  These issues in general, and a couple of current cases he discusses, have policy implications for the new leadership at the FDA.

At InsureBlog, Mike Feehan has a piece on Wellpoint's recent spinning off of its in-house PBM, About Wellpoint's PBM Auction, and future implications for prescription costs.


Ill and Uninsured in Illinois gives us a simple but eloquent presentation of the difficulty of accessing specialty care while uninsured: The Wait for Cook County Health Care.

At the other end of the spectrum, Health Access WeBlog's Beth Capell asks What are gold-plated benefits anyway? An interesting question, now that the president has indicated that he is open to signing a bill including taxation of health benefits.  (As an aside, Obama's approach -- White House Health Care Summit with stunning transparency, concluded with an invitation to Congress to send him a bill consistent with the policies he articulated throughout the campaign -- is both a refreshing change from the Clinton years and a strategy likely to insulate him from criticism on the exact contours of the plan when it reaches his desk.)

Mao_tse_tungJared Rhoads presents Less government, not more at The Lucidicus Project, discussing the recent report by Physicians for a National Health Plan (the single payor proponents).  I spoke with PNHP's David Himmelstein a little while back, and while he has a compelling argument for adopting a single-payor plan in this country (the savings would be impressive), I still believe that the more pragmatic approach is to make incremental changes in the system before us. 

Taking our cue from Dr. Himmelstein, we begin a bit of a grand tour by visiting our neighbor to the north. 

North of the border, Sam Solomon asks Can Canadian doctors fire their patients? at Canadian Medicine, and says in short, yes, but carefully.

At BNET Healthcare, Ken Terry writes that Massachusetts Needs to Deal With Primary Care Crisis, saying that while proponents of the healthcare reform program in Massachusetts tout it as a model for the entire country, and detractors point to the program's rapidly rising costs, neither side is really focusing on the need for better access to primary care in the state. He also observes that retail clinics are expanding in Massachusetts, and community health centers are pulling in federal cash for expansion.  One observation: retail clinics in Massachusetts are not currently expanding as they cannot find nurse pratitioners to hire.  Also, on a national level, Minute Clinic recently shuttered 90 sites for the season.  Even if they were growing, they are no substitute for primary care.

Looking at a new model of physician practice -- available 24/7, untethered to most of the traditional trappings of a physician practice (including that old-fashioned trope of accepting insurance payments), Ted Eytan, MD is Now Reading: Take Two Aspirin And Tweet Me In The Morning: How Twitter, Facebook, And Other Social Media Are Reshaping Health Care.

Great_Dictator_globe_scene_academy_print_bigGrrlScientist shares her overseas medicine story, Finnish Emergency Medicine: One American's Experience at Living the Scientific Life.  Seemed to work well for her without instantaneous contact back home.  (See my own tale of a close ecounter with an overseas health care system last year as well.)

Here at HealthBlawg, I recently interviewed the CEO of Satori World Medical, a medical tourism company that offers a twist: through an HRA, it funds patients' future years' insurance premiums with a portion of the savings their employers or insurers enjoy as a result of their overseas medical procedures.

Closer to home, many doctors are now leery of online ratings sites, and have started using a service, Medical Justice, to get patients to agree not to post negative reviews as a condition of being taken on as patients.  Dmitriy at Trusted.MD has been following this issue for a while and offers some insights.

Marx Brothers (A Day at the Races)_04_scrubbed_in Jaan Sidorov presents The Worrisome Outpatient Trend: What Does Disease Management Have to Offer? posted at Disease Management Care Blog.  Chronic care consumes 75% of the health care dollar in this country, and needs to be better managed.  Outpatient chronic care is a significant part of the equation.

Care management is also the theme of Julie Ferguson's post on The effect of obesity and other comorbidities on workers comp at Workers' Comp Insider.  In light of a new report which shows that workers comp medical claims can cost three times as much when the injured employee is obese, she makes the case for breaking down the silos between employer-based occupational health and general health programs.

David Williams' post on Wal-Mart and eClinicalWorks over at Health Business Blog concludes with a healthy bit of skepticism about this new EHR offering to small physician practices.

Using the cost per doc put out by Wal-Mart, John Moore does some calculations, and shows in his post The HITECH Challenge: Is $19B Enough to Drive HIT Adoption at Chilmark Research that docs getting wired and getting HITECH incentive dollars will be engaged in a money-losing proposition -- they'd actually be better off financially not implementing EHRs and getting hit with the penalty a few years down the road. 

Speaking of Wal-Mart, it bears mentioning that this day in history marks the anniversary of the Civil War Battle of Bentonville (No, not that Bentonville; the battle was in North Carolina.)

Tinker Ready, at Boston Health News, shares some insights from John Glaser, CIO of Partners Healthcare, on getting HIT right.

Shahid N. Shah presents Client/Server vs. ASP/Web-Based in Healthcare IT posted at The Healthcare IT Guy, since with the HITECH Act and stimulus bill making news, many users are asking if they should purchase software and use it on premises or if they should use a "cloud" package or an ASP/web-based solution.

Metropolis5 In addition to jump-starting HIT, current legislation is giving a boost to research funding.  One pot of funds is time-limited; Glenn Laffel looks at Beaker Ready projects ready for NIH funding at Pizaazz.

Jason Shafrin reviews some of the pros and cons of establishing a government body to conduct cost effectiveness research in Should the U.S. get NICE? at Healthcare Economist.

In The Color of Money: What Sort of School Doesn't Pay Its Faculty to Teach? Roy Poses at Health Care Renewal puts academic medicine on the spot, saying that some leaders have abandoned core missions in favor of collecting "taxes" from medical faculty, which makes faculty more dependent on commercial interests.  Strong words indeed, and an issue that needs to be rolled out front and center together with other payment issues if there is to be a wholesale revamping of health care financing in this country.

For those brave enough to enter the land of credit default swaps, Joe Paduda, at Managed Care Matters, examines the reasons for propping up AIG and why it may fail anyway.

And finally, to leave you with some doom and gloom from The Health Care Blog to ponder, Brian Klepper and David Kibbe ask Is the healthcare economy rightsizing?

Thanks for visiting HealthBlawg for this edition.  Please see me on twitter too, and join us again next time for Health Wonk Review.

David Harlow
The Harlow Group LLC
Health Care Law and Consulting

March 11, 2009

Steven Lash, CEO of Satori World Medical, speaks with David Harlow about medical tourism

Steven Lash, President and CEO of Satori World Medical, spoke with HealthBlawg last week about Satori's take on medical tourism, including its method of sharing cost savings with consumers who use Satori's services through employer-sponsored health plans.

The audio file of my interview with Steven Lash (about 20 minutes long) is available for download/podcast. A full transcript is at the end of this post (and in the linke transcript).

Sharing cost savings with employees through Health Reimbursement Accounts -- funded through tax-deductible contributions by the employer if an employee uses an overseas medical service, and are used to pay for an employee's health insurance premiums, deductibles and copayments in future years -- is one of the Satori innovations.  Lash distinguishes his offering from that of the Hannaford's-Aetna medical tourism plan which was announced with great fanfare, led to no employee taking advantage of an overseas procedure, and brought out a domestic provider that offered to match the overseas pricing Hannaford's had obtained.  He also presents a number of other aspects of his company's program in our conversation, including patient intake, patient choice, and quality assurance through selective contracting with JCI-accredited overseas providers for a limited set of services.

There are wildly varying estimates of the numbers of medical tourists originating in the U.S. -- 50,000 to 750,000 a year, depending on who you ask and how you count -- but that number seems likely to go up before it goes down.

David Harlow
The Harlow Group LLC
Health Care Law and Consulting

Interview of Steven Lash, President and CEO of Satori World Medical

March 6, 2009

David Harlow:  This is David Harlow on HealthBlawg, and I have with me today the President and CEO of Satori World Medical, Steven Lash.  Hello, Steven.

Steven Lash:  Good afternoon, David. How are you?

David Harlow:  Very well, thank you.  So Satori is a new entrant on the medical tourism field and I am interested in hearing from you about what sets Satori apart.

Steven Lash:  Great. I think there are several aspects that make us very different than everybody else currently in this space.  First of all, we have a superior quality assurance program and that’s on several levels, David. First of all we have a full time Chief Medical Officer who is board-certified and a fellow, a general surgeon who sets medical travel guidelines and policy in concert with our medical quality advisory committee, which is made up of leading physicians in their subspecialties.  Secondly, we performed a significant due diligence effort that included Dr.  Johnson as well as our VP of Network Development, Naimi Tanha, where they went to fourteen hospitals in seven countries over forty-five days, looking at specifics having to do with quality measures, mortality statistics, infection rates, blood-handling processes. They toured the facilities, and Dr. Johnson even scrubbed into surgery and observed surgical techniques at all the hospitals that are part of our network.  The third thing that makes us different is we started and specifically are working with patients that have financial sponsorship so as a result of that we have set up all our processes and infrastructure to match what health plans currently require for domestic networks, so Ms. Tanha, who’s our VP of Network Development, spent twenty years in California developing and managing networks for Aetna, Blue Shield and HealthNet, and she has duplicated those requirements internally here in the company as well.  The hospitals internationally are contractually obligated to participate in quality audits, quality reporting, et cetera.  A hundred percent of our hospitals are Joint Commission International accredited which is really our baseline because our quality program goes into significantly more detail than that, but that’s sort of a gating issue for our quality program.  Finally, one of the most unique aspects of our program is that, for the first time, the patient will get to share in the savings, who has a financial sponsor, so in other words if a patient needs a hip procedure say and it costs sixty thousand in the US and it costs twenty thousand dollars at one of our network facilities. That forty thousand dollars in savings: the patient will receive a portion of the savings through a health reimbursement account and that’s really what sets us apart.  We put a patent around our business model and for the patient to share in the savings, plus it’s a hundred percent medical benefit so there is no co-pay and no deductible so there’s a real economic incentive for people to take a serious look at the quality of care overseas and the ability to participate in some of the savings.

David Harlow:  So this is a sharing of savings with patients who are in self-insured plans through their employers or through third party payor plans as well?

Steven Lash:  Both, or in unions or associations or public sector employers.

David Harlow:  Now one employer who had engaged in a similar sort of plan -- not through your company, obviously --  Hannaford’s, a regional supermarket chain, has engaged with Aetna in setting up a program that basically gave their employees the option to go overseas at much reduced cost for services or obtain them locally and while they certainly got a lot of press for setting up that program, it turned out that nobody took advantage of it.  Do you have a concern about patients, members, employees being scared off, if you will, from the idea of going overseas for healthcare services, particularly for an involved surgical procedure?

Steven Lash:  Well first our comment on the Hannaford experience: I am familiar with it.  Actually, the Aetna executive who put that program together sits on our medical quality assurance board so we are very familiar with it, and the hospital they contracted with is a very outstanding hospital, in fact that hospital is in our network as well.  I think there are two differences: Number one, there wasn’t an organized program around it, in other words we are a one-stop shop, where the patient makes one call and we take care of all the travel, all the hotel, everything is done for them, we kind of demystify it for them and that wasn’t the case in the Hannaford’s program.  Secondly, a companion goes along so somebody is a accompanying you on your trip. And the third thing that is again the most important is my understanding in the Hannaford experience, they only waived the co-pay and deductible which was about fifteen hundred dollars or two thousand dollars.  Our program is much more robust in terms of the sharing of the savings and for somebody making fifty thousand dollars a year who could have the opportunity of, let’s say, ten thousand dollars deposited in an HRA, where they won’t have any medical expense for two or three years is a lot more of an incentive then just waiving fifteen hundred or two thousand dollars’ co-pay and deductible, and I think in essence that’s why they haven’t seen much success.

David Harlow:  Just to be clear, HRA is a Health Reimbursement Account and that is a tax-free account that patients, members can draw on to pay medical expenses in subsequent years.

Steven Lash:  That is correct. It rolls over, year over year.  It is tax free to the employee and tax deductible to the employer so it kind of wins on both sides of the tax equation.

David Harlow:  Right.  So that payment assumes that the employer is exposed to the whole cost of the procedure, otherwise the employer wouldn’t have that excess money to pay out, isn’t that correct?

Steven Lash:  Well, it could be if it’s through a health plan, through an HRA, there could be premium rebates or premium discounts that can be applied from a health plan to the employer, so there are ways to have that employer receive that benefit even if it’s a fully insured program.

David Harlow:  Okay. Now I am interested in thinking about the volume of services, the volume of patients who would be going through programs such as these.  There have been wildly differing numbers put out there by different consulting firms in different studies ranging from seven hundred fifty thousand Americans making use of medical tourism in the past year to under fifty thousand.  I’m wondering what your sense is of this market and what portion of this market do you think you are able to capture with your new venture?

Steven Lash:  Well I’m not sure I can give you an answer of what's the size of the market -- it’s probably in between those two numbers -- because there is no real reporting agency that captures it.  I mean, there are a lot of people along the border that go across to Mexico for dental care, and not having seen the work papers on either organization I am not sure what's the right number but what I am confident of is we are just seeing an industry in its infancy that is going to start to take off and develop into a very large mainstream service for the delivery of healthcare in this country and the reason I say that is because there is I think now an acceptance that there is significantly high quality care delivered outside of the United States even though Americans tend to be very American centric.  I tell the story, when I was growing up I was going to buy a transistor radio, and I told my father I am going to buy a transistor radio, and he asked me what kind, and I told him a Sony, and he said: Sony? That’s Japanese, that’s crap technology.  He said, you know you ought to be buying an RCA.  We all know the end of that story.

David Harlow:  Yes.

Steven Lash:  And I think that there is a kind if grudging acceptance now that there is high quality care available internationally, and number two is, I think our model, with  cost savings participation by the individual, is truly unique and innovative, and with that, people will start to take advantage of the program and the quality that’s available internationally.

David Harlow:  Now a year or so ago there was famously a union representative calling out a company that was requiring a union member to go overseas for a surgery and essentially faced down this employer -- I believe it was an industrial employer in the Midwest -- and ended up having the union member get his surgery in the United States, saying you can’t force him to go overseas.  Do you think that anyone in that sort of position would see the financial benefit of a program like this as some sort of coercion? Or some sort of a coercive factor in limiting patients’ choice?  Do you see that, do you see the backlash against something that’s limiting patients’ choice in a negative way?

Steven Lash:  Well, you see, I think the beauty of our program is it is totally a hundred percent consumer choice, we don’t ask any network or anybody to reduce their patients’ -- I mean the employees’ -- options.  We become an additional benefit so they can still and are free to choose any provider that’s in their current network, in fact we almost insist that they don’t reduce anybody or any other network in their health plan.  So we are just an addition too, because this is consumer directed, the consumer has to make the choice, we are not forcing anybody to do anything and, you know, the word of the current period is transparency, there’s transparency around our quality and transparency around the economics and people are free to make any choice they want, they stay in country domestically, they know exactly what they have and what their economics are and what the quality is.  If they select the Satori Global Provider they know exactly the quality, they know the economics and it’s their choice, we don’t influence it one way or the other.

David Harlow:  Great.  I guess that was the reaction that some people were having to other sorts of plans where it was not a choice, where that was the sole option provided.

Steven Lash:  Yeah and that’s not something we subscribe to at all.

David Harlow:  Okay.  Another question that people often raise about medical tourism is what happens in case of complications?  Either complications that arise while overseas just after going through a procedure, or complications that may turn up a couple weeks after returning home.  Have you had experience to date with situations such as that and how have those been handled, or if not how would you anticipate those being handled?

Steven Lash:  Well we have not had that as an experience to date.  A couple things: number one, all our patients are vetted in terms of their ability to travel and the medical guidelines that our quality advisory committee and our chief medical officer implement.  So for example a patient who is obese, had a stroke, has diabetes, is not going to be eligible to go anywhere in our system because we know there are going to be complications and issues with that, so that’s kind of the first thing.  Right now, the existing companies don’t do a medical triage whatsoever in terms of their abilities for travel, so that’s kind of the first distinction.  So there are going to be patients that want to use Satori that we will not allow to participate in our program, because we think there is a health risk there or medical risk there.

David Harlow:  How would that screening be done?

Steven Lash:  We review the charts -- because we take a medical history and our chief medical officer is involved and we would make sure they meet the medical travel guidelines that we have established.  So that’s kind of the first situation, so we eliminate kind of out of the chute, if you will, some of that potential.  The second thing that’s different from our program is all our patients have relationships with an insurance company, or some sort of financial sponsor, and a physician.  So we schedule their follow up care before they leave the country.  So, in other words, if someone is going for a hip overseas, we have a follow up appointment with an orthopedist before they leave.  So that is kind of another way which we mitigate some of the negativity around medical travel.  The third issue: our institutions and our centers are the best of the best.  Now that doesn’t mean that something untoward couldn’t happen.  I can tell you that for surgical procedures that we are selecting and utilizing -- because we are not doing hundreds of procedures, we have a handful that we are doing -- we are going to do up to about twenty -- that the surgeon knows within twenty-four, and maybe at the latest seventy-two, hours your course of treatment and your recovery as to whether or not you are going to do well or you are not going to do well and so that all is managed.  Our patients spend an average of seventeen days in country, so there is plenty of time for follow-up care and making sure that they are on the road to recovery prior to them getting on a plane and being released for medical travel.

David Harlow:  Okay, you anticipated my next question, which is what is the range of services for which you’re contracting with the overseas providers?  You mentioned a handful, or a limited range, of those procedures, and what would those be, what sorts of procedures are they?

Steven Lash:  Okay.  First of all, all our procedures are non-emergent, high-cost surgical procedures.  We have four cardiac procedures, we have four orthopedic procedures, so the cardiac are defibrillator, pacemaker, valve and CABG, the orthopedic is hip replacement, one knee, double knee and hip resurfacing.  We are currently in the process of doing our due diligence with the institutions, we are going to be adding this year shoulder, spine, bariatric, hysterectomy, prostatectomy -- I think that’s it, and then we are going to be adding, kind of as an accommodation to some people that have asked us to, dental in a limited network and then cosmetic in a limited network.

David Harlow:  Okay.  Are these procedures available at all of the facilities in your network or do they specialize?

Steven Lash:  No, and the reason they don’t is because of our quality program.  There are, for instance, hospitals in our network that do cardiac surgery, but we will not approve patients to go there for cardiac surgery because they don’t do enough of them to meet our quality standards.  We use things like HealthGrades as an example, Leapfrog Group, and other measures to determine the quality so we screen our institutions to make sure they are doing enough volume for our patients to go there because, as you know, it’s like anything:  if you do enough of them you get very good and we don’t believe that if you do fifty open heart procedures a year -- basically one a week -- you get very good.

David Harlow:  Right, that’s not where I would want to go.

Steven Lash:  Right, and we don’t want to send our patients there either.  So we do not authorize them for certain procedures if they don’t meet our volume and quality thresholds.

David Harlow:  Got it. So that’s on top on the Joint Commission International accreditation?

Steven Lash:  Right.  That’s another difference between our network and the existing ones, people can choose to go wherever they want.

David Harlow:  Okay.  What sort of volume are you seeing to date?  I don’t know how much of this information you’re comfortable sharing, but I would be interested in any information you are willing to share about enrollment in your programs to date -- whether it’s through the McGregor agency or others -- and what sort of numbers of overseas procedures you have been seeing to date.

Steven Lash:  Well, we do not disclose that information but I can tell you that we are gaining a significant amount of traction in the marketplace, and we will be happy to put you on our list for announcements and all that.  We anticipate -- I would be happy to share this with you -- several hundred patients receiving services this year.

David Harlow:  Okay, great.  To wrap things up, I would be interested in your reaction to the White House Health Care Summit yesterday and thoughts about whether anything that is likely to happen in the US in the next year or so may have an impact one way or the other on your business and the services that you are providing.

Steven Lash:  Well first of all I certainly applaud President Obama for getting all the constituencies together to talk about health care reform because it’s certainly -- as somebody who has been in this space for about twenty-five years -- certainly it’s a difficult one to really master because some of the flaws in our system are so endemic to the way our country has grown up that I am not sure that it’s going to be easily cured.  I do feel that the program that he is talking about and the path that they are talking about moving down is only going to be helpful to our company and our business, for a couple of reasons.  First of all, one of the things that we do is, by providing access to these international centers of excellence at their cost, we help US organizations compete on a global basis by lowering their health care cost and having them having the same access as their international competitors do to a lower healthcare cost because as you know health care cost is a huge driver on the P&L in today’s environment.

David Harlow:  Right.

Steven Lash:  The second thing is if they are talking about providing more people access to insurance plans, that will give rise to us as an opportunity. You know, the sense that I have from the reports that I have read out of the summit, there is nothing but looking at cost savings and new techniques for lowering costs and to the extent we provide a competitive environment for that to happen, I think that’s terrific.

David Harlow:  Well, Steven, thank you very much for taking the time.  This is David Harlow at HealthBlawg and I have been speaking with Steven Lash, President and CEO of Satori World Medical. Thanks again Steven.