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» antigua and the american healthcare refugee
Wednesday, September 21, 2005 - One afternoon ten years ago I was confronted with a medical dilemma. A sixty year old unemployed nuclear physicist presented in my office with sharp abdominal pain. I could see in his eyes that the pain was also associated with considerable fear and a sense of desperation. You see, he had entered into that most vulnerable world of the uninsured, unemployed, with home ownership. As an older male with assets, he could not qualify for welfare, nor would Medicare be of assistance. His company had left him exposed without medical benefits at the very time in his life when he needed them the most.
The fear etched on his face was well founded. While his diagnosis was fairly benign involving bilateral inguinal hernias and a peptic ulcer, the cost of such care became the real issue. I naively suggested that he call different hospitals to get a quote of what a hernia repair would cost. After much calling, being placed on hold, being told that the cost depended on which insurance he had, etc; He was finally given a figure of $14,000, not including surgeon's fee or anesthesia.
With his head bowed, and with resignation he assumed the worst. The total bill would come to $20,000, requiring a lean on his house and a mortgage he could not afford. Looking for a cure for this economic dilemma became more of a challenge than the surgery! It occurred to me that I had just spent some time in a mission hospital in Ecuador working with US medical missionaries. Why couldn't they do the same for my patient? After some phone calls, the arrangements were made, and my patient flew down to Quito where he had bilateral hernias repaired as well as having an upper endoscopic exam for the treatment of his peptic ulcer.
He returned a month later, with a tan and very relaxed. The surgery had gone well. The ulcer had been treated, and he had spent 4 extra weeks in a resort recuperating and catching some sun. The total cost had been $2,400 including air fare. He was pleased and I was elated. I had found a possible solution to caring for the uninsured. However, before I could send my next patient down, I received a letter from the hospital surgeons requesting that I no longer plan such referrals. They had the impression that American doctors could still be sued in the states for work done overseas! While I thought that they were probably overreacting. I stopped. The idea stuck, however!
Some years later while vacationing in the Caribbean island of Saint Maarten, I decided to visit the local hospital. My wife knows how I think, and didn't object. The local situation was quite grim. Money was tight and the hospital had to declare bankruptcy. Medical tourism intrigued the director of the hospital, but local and Dutch politics and regulations became insurmountable. The World Bank however showed some interest and called our clinic after reading Dr. Alieta Eck's presentation before the Joint Economic Committee of the US Congress in Washington. They asked for information to be published in an economics research paper on medical tourism.
Over the years, I have seen many patients, especially latinos, seek surgical care back home where the costs wouldn't be prohibitive. I have seen the uninsured become so desperate that they have become medical refugees driven offshore by medical bills that are on average 400% higher than what insurance companies have had to pay. I have heard of hospitals placing leans on trailers for unpaid bills. Health costs have become the leading cause for bankruptcy.
Why do the uninsured pay 400% more for the same service than the negotiated price set by wealthy insurance companies? Why do the working poor get phone calls demanding payment one week after service, when the insurance companies can delay and demand that bills be resubmitted?
It also occurred to me that hospitals and their doctors operate under tremendous burdens. Unfunded mandates require that hospital care for all regardless of their ability to pay and regardless of their legal status. State budgets are overwhelmed with charity care and Medicaid costs. Doctors face a 25% increase in malpractice costs and a 25% reduction in Medicare reimbursements. All of this occurs in the harsh environment lawsuits and governmental regulations and fines. These questions help frame the answers. They make us look outside the box.
While this has been on our minds, in God's providence, other people have come into our lives. Rev. Chris Pierce, of the Emmanuel Reformed Episcopal Church in Somerville met with a fellow pastor in Brooklyn last October. Finding he was from Antigua, he asked about the country. In that brief encounter he learned that the island had a big hospital building, a big debt and no way to operate it. In addition, the functioning government hospital was old, decrepit, and outdated, with an image of inadequate care in the minds of the Antiguans.
Rev. Pierce happened to mention this to Dr. Albert Johnson, an orthopedic surgeon at Somerset Medical Center. Dr. Johnson said, "Have you met the Ecks?" Within a few weeks, Rev. Pierce, the Consul General of Antigua and Dr. Johnson met with us in the Zarephath Health Center where a decision was made to visit the island.
In addition, Rev. Pierce had recently met a fellow Episcopalian from South Carolina who happened to be a Professor of Management at the Moore School of Business in the University of South Carolina. We thought that in order to have credibility, we would need someone with business acumen to develop a business plan to make this work.
And so Rev. Pierce, Professor Bill Sandberg, my wife and I made a trip to Antigua to meet with the Prime Minister and speak with the leaders on the island.
Antigua and Barbuda occupy roughly 187 square miles with a population of some 71,000. The people speak English as they were for many years governed by Britain. The island's economy is largely tourist based. Visiting the island with Rev. Pierce was a trip! Having visited the island once before, he seemed to know everyone. He also drove on the wrong side of the road, like they do in England. In a curious twist of roles the Reverend drove while the passengers prayed!
We met with the Arch Deacon of the Anglican Church, Peter Daley. We spent hours learning about the island and the church. We also toured the old Holberton Hospital and met with its dedicated staff. We met with the Prime Minister Baldwin Spencer and the Consul general MacChesney Emanuel. I'm not sure what the Prime minister thought after meeting with a husband and wife doctor team, an Episcopalian Minister and a professor of business. This kind of team could only be put together by a God with a tremendous sense of humor. As it turned out, we were able to focus on the most significant issues. We were able to come away with a tremendous appreciation for the leadership on the island. We were also made aware of the timeliness of our visit and the merging needs of the islands and our own.
The health care crisis should not be wasted, it should be used as a way to shake off apathy and think creatively. Due to the malpractice climate, thousands of our most experienced doctors retire never to volunteer. What a waste! Due to the regulatory environment new technologies never see the light of day. Due to burdensome regulations requiring certificates of need, competing institutions are denied the opportunity lower prices. Due to the liability crisis, $160 billion dollars each year are wasted. One third of all businesses will be sued in the coming year.
Answers
- Outsource surgery using volunteers and retirees.
- Charitable focus without liability.
- Use offshore sites to train doctors in new technologies. World class scientists and technicians can meet in a resort environment to learn and apply technologies.
- Resort medicine for recovery and observation. No drive by deliveries!
- Medical timeshares as an alternative for strapped corporations tired of paying premiums.
One last thing-- last month, I went on a mission trip to Peru. There I saw a child, under two, who had been burned as an infant when her mother had a seizure while holding a pot of boiling water. She lost her right hand and her face is badly disfigured. Part of our dream will be to bring patients like these together with doctors from the US who would like to donate their services from time to time. Mount St. John's Hospital will be the perfect venue.