Accidental Tourist: Visiting the Bumrungrad Hospital in Bangkok

There’s been a lot of recent speculation that more Americans will be taking their elective medical problems overseas. In 2008, Deloitte’s Center for Health Solutions estimated that 750 thousand Americans travelled overseas for medical care in 2007, and forecast a eight-fold increase by 2010 In a 2009 update, Deloitte found that the 2008 financial crisis devastated overseas medical travel, but still forecast 1.6 million US citizens going abroad for medical care in 2012.

Among overseas medical destinations, no facility is mentioned more than Bumrungrad (last syllable rhymes with “hot”) Hospital. Bumrungrad is a privately owned but publicly traded 550 bed acute care hospital in central Bangkok. On a recent trip to Thailand, I stopped at Bumrungrad to find out what all the shouting was about and was really impressed with what I saw.

Bumrungrad’s CEO is a courtly, silver-haired Virginian named Mack Banner, who spent most of his career in the US investor-owned sector. Though the hospital was founded in 1980, it moved into its new facility in 1997, just in time for the Asian financial crisis. The facility was Joint Commission (International) certified in 2002, and one fifth of its physicians are US Board certified in their respective specialties.

In 2008, the hospital opened a beautiful 21 story Clinic building next door, housing 30 specialty clinics and most of its medical staff. Bumrungrad’s Clinic Facility is Mayo-esque, enabling patients with particular specialty problems to be worked up, evaluated and cared for on a single floor. The hospital subsequently renovated its inpatient rooms, which resemble those of the Asian-themed Washington DC Park Hyatt in elegance. The hospital is a sunny, happy place, with apparent high morale and very high service standards. English is spoken widely throughout the hospital.

Bumrungrad’s physicians are independent of the hospital economically, though the hospital provides billing and other clinical support for its medical staff as if they were a group practice. Bumrungrad’s home grown electronic medical record system was impressive enough to be purchased by Microsoft, and it became the core of their Amalga product.

According to Banner, Bumrungrad sees one million patient encounters in a given year (which include inpatient admissions, outpatient clinic visits and diagnostic tests). Perhaps not surprisingly, given that it’s on the other side of the world, only about 5% of those patient encounters are Americans, divided roughly 50-50 between the American expatriate community in Thailand and near Asia and American tourists in Asia.

Most of the latter group of Americans Banner referred to as “accidental tourists” who encountered a medical problem while traveling and ended up at Bumrungrad for their medical care. He put the number of American patients who travelled to his facility for elective care at “a couple thousand” in a given year, hardly a flood, but understandable given the lack of non-stop air service from the US. American patients are outnumbered two to one by patients from the Middle East, whose numbers have grown ten-fold in the past decade.

Fully 71% of Bumrungrad’s patients pay cash for their services, and the hospital defines its trade area as a six-hour flight circle around Bangkok. So Tokyo, Beijing, Shanghai, Taipei, Manila, Seoul, Kuala Lumpur, Singapore, Sydney, Nairobi, Mumbai, Dehli and the United Arab Emirates all fall inside the circle. The hospital maintains sales liaison offices in seventeen cities inside the circle that connect to the business and diplomatic communities in those cities. One of the most active of those offices is in Mongolia!

However, Bumrungrad is also a significant urban hospital serving central Bangkok. It operates an emergency room, a neonatal ICU and has extensive urban hospital service lines and obligations. Its physicians do medical outreach to long suffering Burma, next door, and its Medical Foundation funds care for indigent patients in Thailand.

Package prices for medical care at Bumrungrad are remarkable by American standards. A total joint replacement (hip or knee), including diagnostic tests, all physician fees and hospital care, can be done at Bumrungrad for around $16 thousand. US and coronary bypass graft surgery for a little over $30 thousand. Low Thai pay scales certainly help make the care affordable. Veteran ICU nurses at Bumrungrad make about $2500 a month US, plus health insurance, while starting nurse salaries approximate $800 a month.

Complication rates and infection rates are lower than or equal to those in comparable US and international health facilities. The hospital maintains a Cost Estimator on its website enabling interested patients to see the range of charges for recent patients with 46 different clinical problems.

Bumrungrad’s medical staff is virtually 100% Thai national. The father of Thailand’s King Bhumibol Adulyadej was a physician who trained at Harvard. (The present King of Thailand was actually born at the Mt. Auburn Hospital in Massaschusetts.) For this reason, Thai culture highly values medical training. One gets the impression that the Thai medical community is virtually 100% self-sufficient, though it maintains proud linkages to international training venues.

Thai medical education standards are very high, and a significant number of Thai medical graduates do their fellowship training in Britain and the US. But rather than seeking employment in the British National Health Service or entering practice in the United States as their elders did, an increasing number are returning to practice in Thailand.

Bumrungrad is seeing increased domestic competition for international travelers from the massive Siriraj Hospital, a principal teaching facility of the Mahidol University (named after the King’s father) whose formidable campus looms over the West Bank of the Chao Phraya River. Many of Bumrungrad’s physicians trained at Siriraj. Siriraj cares for the Thai royal family, and recently built a shiny new 345 bed private pavilion for its medical faculty.

Banner acknowledged that competition for the international medical tourist is also heating up. A decade ago, their main Asian competition was the Mt. Elizabeth Hospital in Singapore. But Duke, Johns Hopkins, Cornell and Cleveland Clinic are opening projects in China, Qatar and the United Arab Emirates that will enable middle Eastern and Chinese patients to receive state of the art private care in locations closer to their homes.

While it is not reasonable to expect massive numbers of Americans to travel half-way around the world to Thailand, Bumrungrad made an impressive case that world medical standards have caught up to America’s. While the US continues to supply much of the rest of the world with biomedical research and clinical innovation, it’s not obvious why citizens of the Pacific Rim or central Asia need travel to America for world-class health care. It’s available to them in their own back yard.

Note: Author received no consideration for his visit or writing this posting. Bumrungrad’s management graciously endured his visit.

Jeff Goldsmith is president of Health Futures Inc, which specializes in corporate strategic planning and forecasting future health care trends. He is also the author of “The Long Baby Boom: An Optimistic Vision for a Graying Generation.”

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  8. As I’m reading your comments here, I am struck by the unspoken, or unaddressed issues of organization. I see lots of talk about outsourcing non-critical patient care jobs, swipes at poor management (I agree that American hospitals are, by & large, the MOST inefficiently run facilities), etc. Yet no one is addressing the glaring issue of workflow.

    Last time I visited a hospital, it was because I’d sliced my hand & arm open. I was the FIRST person in the door to the ER, yet it took over 2 hours before I was led back to a care room. This after no fewer than 8 other people came in for ER care.

    Meantime the jerkoff manning the front desk yelled at me because I had let my blood-soaked towel fall onto a chair. Mind you, I was almost fainting by that time because I was losing blood.

    It took 8 hours, from the time I sat down in the waiting room, to the time they checked me out after stitching me up, for my emergency care visit.

    Workflow. I’ve worked in industries for years now where efficiency (or lack thereof) is determined by intelligent organization & workflow. I have never seen anything like what I saw on Morgan Spurlock’s TV segment about his visit to Bumrungrad.

    So while we’re talking about outsourcing what YOU believe are non-critical positions, ostensibly to reduce costs (that’s a laugh, it will not have the desired effect because IT’S NOT THE PROBLEM!) -from a consumer standpoint, inefficiencies in organization & workflow are what I see as the culprits at the point of care. Add to those the bloated insurance administration costs, overpaid doctors (necessitated by again, the bloated healthcare insurance mafia who seem to function as gatekeepers determining who will get what level of care, how much, live? Die? And let’s not forget malpractice insurance!) and we’re STILL playing pin the tail on the donkey, without ever addressing the REAL issues impacting the cost of healthcare in America.

    It’s a farce. I would gladly go overseas, either to India or Thailand, for procedures as simple as yearly physicals. American healthcare -as impacted by healthcare insurance mafias, grossly overpaid hospital administrators AND doctors (due to malpractice insurance?) relative to what they could achieve if they simply thought about applying what they learn in university.

    Don’t blame the nurses or their comrades for the failings of those whom we KNOW are the real cause of out-of-control healthcare costs.

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  10. Look on the website of the hospital and check the profile of the doctors VERY carefully, then cross your fingers and hope for the best. The hospitals are very clean and the nurses the best in the world but what shall I say about the doctors??
    Also check out the Vejthani hospital, they have a joint centre and do more treatments/ops than Bumrungrad, and is cheaper.
    Be alert all the time, dont just believe what you are told by the staff

    Kingston hotel B1500 per night, shuttle service

  11. Look on the website of the hospital and check the profile of the doctors VERY carefully, then cross your fingers and hope for the best. The hospitals are very clean and the nurses the best in the world but what shall I say about the doctors??
    Also check out the Vejthani hospital, they have a joint centre and do more treatments/ops than Bumrungrad, and is cheaper, same doctors
    Be alert all the time, dont just believe what you are told by the staff or doc

    Kingston hotel B1500 per night, shuttle service

  12. How does one book an appointment for treatment at the Bumrungrad Hospital for physiotherapy? My daughter has a C5-6 spinal cord injury which left her a quadriplegic 6 years ago. We would like to go there for 2-3 months this summer. Which hotels nearby would you recommend?

    We live in Toronto – Canada and any insight would be greatly appreciated.


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  14. Could you contact me at jamesrobertgoldberg@gmail.com? A major television network is doing a piece on medical tourism with special focus on things that went wrong at Bumrungrad. (My son was killed there, we believe to harvest his organs) in 2006. I wrote a book, The American Medical Money Machine which is available on Amazon.

    Please respond ASAP.


    Dr. James Goldberg

  15. Mack Banner is a former executive of National Medical Enterprise, now Tenet Health Care.

    Ask him to supply you their internal report concerning the death (murder) of my son Joshua Goldberg.

    My book, the American Medical Money Machine will help to shed light on Mr. Banner…..he’s as slick as motor oil!

    Book available on Amazon.

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  18. All is not about costs. I had a total knee replacement done – after an hour on the operation table in theater the doctor stopped the operation because he did not have the correct size knee for me (I am a big built westerner), my knee already cut open!! And during consultation i did ask if he can do an operation for my size of a guy. Some of these guys are a joke!
    Some hospitals in thailand are super clean, the nurses the best in the world, but many doctors do not know what they are doing (I have more examples after 7 years of living in Thailand) but they do every test under the sun and of course they know how to charge! Sorry but Bumrungrad is absolutely overrated because of the above

  19. I have lived in Asia for a number of years and up until recently, I used Bumrungrad almost exclusively for the medical treatment of myself and my family. However, due to a couple of very unsatisfactory treatments that my wife and I have received in the past 12 months, we will never go back there. Whilst they have great facilities, and their doctors are extremely good in terms of technical expertise, the hospital has become nothing more than a production line i.e., get as many patients as possible through the doors, and then recommend the most costly treatment without ever discussing or considering less expensive and/or alternative and less invasive treatments. I would suggest that more than 80% of their clients now come from Arab countries who are cashed up and who mostly would know nothing about what a good and caring medical provider actually looks like. I have spoken to numerous people from western countries, who like me are disgusted in the level of service and care they have received from Bumrungrad and refuse to go back there. If you are 100% certain of the exact type of treatment / surgery that you want/need, then Bumrungrad is for you, but if you want your doctor to explore and discuss options e.g., non surgical procedures, or less invasive procedure; go elsewhere!

  20. Continuing . . .

    And, I have to report that I am dissatisfied with the quality of care provided. First, during my initial visit with the surgeon, I felt very rushed, with his terse responses to questions and his unwillingness to engage in an interactive discussion of the focal problem. This behavior, combined with his difficulty in speaking clear English, made for a frustrating first encounter. But, I decided to proceed nevertheless, given that he invented this particular colorectal technique and has trained a number of colorectal surgeons in how to do it.

    After a brief examination of my derriere, he assured me that it was superficial problem and would be “no problem” to repair. I had brought along MRI films on a DVD and asked if he wanted to see them (so that he could gain an idea as to the location of the internal opening and the fistula track). He waved away the DVD, commenting that he didn’t need to see them because he could tell that the problem was superficial.

    The long and short of it is that as I was waking up from the procedure the following day, he mumbled something about not having been able to find the internal opening and therefore having to do a fistulectomy. No further explanation — which I would thought was warranted, given that the procedure differed from what we had agreed to the previous day. Even though still dazed from the nerve block and anesthetic, I tried to engage him a discussion of what he did and the implications of the same — e.g., was the internal opening still there and what was the prognosis for a new fistula down the road. But, he was in a hurry. “I have other patients to see,” he said, as he left the room.

    Later that evening he stopped by my hospital room, and I again sought to receive an explanation as to exactly what procedure(s) he had done and the longer-term implications of them. All I could learn was that he did a combination LIFT and fistulectomy, which he later wrote on the medical record as a “fistulotomy. (When I later asked him to make it clear that he had performed a fistulectomy, not a fistulotomy, he responded, “They’re the same thing” — which they are NOT.)

    Among other strange comments that he made during the brief visit were the following:

    > the fistula had been a “high, transsphincteric” one, not the superficial intersphincteric type that he had assured me was the case. (This representation struck me as extremely strange, in that four (4) other CRS with whom I had consulted in the States before deciding to have the LIFT done in Thailand — including one who had inserted a seton at one point to keep the track opening for draining — had all described it as a superficial intersphincteric fistula. I asked him to draw out the track; and, what he drew bore no resemblance to what other CRSs had drawn out after their examinations in the States.)

    > I asked him to tell me what he did. He hurriedly ran through a confusing description that indicated that he had left the internal open untouched (given that he said he couldn’t locate it), and had “cored” out the fistula track. I later learn, when visiting his fellow (during my last post-surgery visit) that he had also left the fistula track intact in the space between the internal and external sphincters, removed that portion of the track that passed through the external sphincter. (In brief, then, what he described in the scribbled medical record as a “combination LIFT procedure fistulectomy” was in reality only a fistulectomy of the track as it passed through the external sphincter. He had not cut through the track in the intersphinteric space to tie the two ends so that nothing else could move from the internal opening down the track. (At one point, he mentioned that track in the intersphincteric space was “very soft, very soft” — the meaning of which he didn’t explain.) And, he had not closed off the internal opening (because, he said, he couldn’t find it).

    Yet, fee was that of a full LIFT plus fistulectomy, i.e., app. $3,015.

    I had to return 10 days after my discharge due to pain in the wound area, as well as what seemed like stool or liquid incontinence. He did a quick examination, mentioned that there was a “little infection” and then prescribed additional antibiotics. Still wanting greater clarity around what he did and the longer-term implications, I tried to draw more information out of him. But, after his brief examination, he busily writing — which when done was followed by an “okay, you can go now.”

    It was only when I met with his fellow during my second and final post-surgery visit that I learned that (a) contrary to what the surgeon had stated several times, the healing period required would be more on the order of 12 to 14 weeks, not the “4 to 6 weeks” that surgeon had tossed out (several times) PRIOR TO the procedure and, (b) no actual LIFT procedure had been done, only a fistulectomy of the track as it passed through the external sphincter.

    I feel strongly that I was taken advantage of in a “bait and switch” manner. At this point, I can’t be certain what he actually did and why. All I know is that I am still in pain. Whether the pain is due to the self-absorbing sutures that are apparently still in place at a very sensitive location in the derriere (are get pressed hard whenever I sit) OR due to a continuing low-grade infection — this I do not know.

    What I do know is that, based on my personal experience, I would NEVER recommend this place to anyone else, particularly if the need is for any kind of colorectal procedure. Not is it over-priced and something of an assembly-line approach to medical care, some doctors (including mine) can barely speak English, are taciturn to the point of being dismissive and rude, and are in too much of hurry to finish with a given patient to answer questions in meaningful degree of thoroughness. As far as I am concerned, I was thoroughly ripped off.

    “Caveat emptor.”

  21. Well, I just returned from a visit to have a colorectal procedure done at Bumrungrad, with the surgeon being the reputed top person in the field.

  22. Hanovera Healthcare, leading Internaitonal Healthcare Consulting firm, reported 1.4 million US citizens had medical treatment while abroad. Less than 30% of these patients actually traveled abroad for the sole purpose of that medical care. Most of the patients receiving care abroad were expatriates, business travelers or normal tourist being treated for illness and injury at the destination. –

  23. Hi, I am doing a research paper on medical tourism. Would you mind sharing with me more detailed information about your experience? We could connect any way you choose and anonymously if you prefer. Of course your information would be strictly confidential! Thank you! Please email me if you’re interested: alanjonesnyc2014@gmail.com

  24. After spending almost a decade living in Asia I quickly realized that we have been dupped. Our medical care here in the US is simply inferior and overpriced. I had horrifying medical care for a hysterectomy I now doubt I even needed in my late 20’s when the Doc inadvertently sliced a major artery and I nearly died. I would have died had my husbands college room mate from UVA not been a mile away, and as a surgeon came in, corrected the mistake and saved my life. I was horribly over medicated with pain killers for two years with shoulder pain in the US then got to Hong Kong and was told by my Doctor to visit some old lady on the corner who manipulated my shoulder ( Ihad horrible pain after trying to teach my daughter a backwards dive went wrong) forabout 8 minutes and it never bothered me again. A Doctor without an ego and desire to be rich sent me to her. Last month after a dentist in Virginia apparently filled a tooth without the root canal it probably needed first I have extreme pain decided to go back to BIDC and get the work corrected by my dentist of several years in Bangkok. For what I will pay for the root canal, crown, plane ticket and week in a REALLY NICE hotel with a great pool and some sun I will still save about $2000! Had my teeth veneered there and they look great. These hospitals and dental offices are packed with Westerners from America and Europe and people who have more money than they know what to do with. Some oil Barren from Dubai I think had 7 wives at Bamrungrad last time I was there. He could afford to go any where in the world but came there. Last time I had my physical at Bamrungrad (an experience you would never believe-you sit and chat with each specialist-cardiologist, obgyn, internal medicine after each series of tests for a long time as they discuss in detail all the test results the day after the physical or sometimes the same day) Many are US educated. For virtually anything I can plan ahead I will continue to go to Thailand for medical care. Not to save money, but because the quality of the care far surpasses any care I have ever had in the United States. The ONLY people I know who THINK we have good medical care in the US are people who have never lived in another developed country for a substantial amount of time. I am leaving this week for Thailand because it’s outstanding medical care. I believe it to be far superior to the care available in the US.

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  26. The doctor I had (Dr. Verapan Kuansongtham) in the Spine center was very sensitive to criticism, even of a mild nature. I had to switch to Bangkok hospital. No problems so far there. Bumrungrad is way overpriced, so it worked out okay.

  27. I have had very positive experiences in my experiences of three different hospitals here in Thailand. They are always efficient, polite and friendly. Apart from minor culture differences, I have found the service to be excellent.

    I have just written a blog post about the ‘funny’ side of my experience in a Koh Samui hospital today. You can find it on my travel blog at:


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  29. Sitting in bed the day after a (apparently unnecessary) bronchoscope turned into a perforated and twice-collapsed lung with a 14-inch drain sticking out of my chest, installed without pain meds at about 12:30am.

    Best part. Third Party Payer Services called me at 7:15 am wanting to know if I was planning to pay for the “extra care” out-of-pocket (and if so could I come down this morning) or if they should contact my insurance company directly.

    Seriously?! I might expect this back in the US, but had heard such good things about Bumrungrad. That of course is why I came to make sure I didn’t have TB. What should have been simple, routine and affordable has become a complete mess, simply due to an instance o negligence on the part o hte doctor performing the procedure, and the anesthesiologist.

    These guys are not getting another red cent from me.

  30. I’ve been to Bumrungrad several times while living in Bangkok and I really can’t think of anyplace I’ve received better medical treatment. The doctors are top notch, speak English, and really seem to care about their patients.

    This is what will make the difference for medical tourism. Some people will always go with the cheapest alternative but if you don’t feel comfortable with your doctor, you can’t have a thriving medical tourism industry.

  31. If patients had the ability to compare costs in the US to that in Asian hospitals, they might be able to make a more informed choice. However it is like pulling teeth trying to get total cost for a procedure from most hospitals in the US. Transparency in pricing may lead to greater opprtunity for US hospitals.

  32. Peter1 –

    Of course every medical procedure carries at least some risk. Failure to diagnose a disease or condition, which was the focus of my comments about safe harbor protection from lawsuits for doctors, account for less than 20% of malpractice cases. A large number of those, I suspect, are cancer cases.

    I’ve also said before that I would prefer to see the remaining malpractice cases taken out of the hands of juries and handled by specialized health courts instead. Juries are too easily swayed by emotion while health court judges can hire neutral experts to rule on conflicting scientific claims. Juries of ordinary people are unqualified for that role, in my opinion.

    The fact is that patients everywhere are subject to the risks inherent in medical tests and procedures. Yet doctors in other countries don’t perceive anywhere near the same need to practice defensive medicine. Why is that? I don’t know but maybe it’s part of our culture of unreasonable patient expectations combined with a litigious mentality among too many of our people.

    I don’t think doctors expect to be immune from lawsuits when things go wrong which is sometimes their fault. I do think they would like to see consistency and objectivity as opposed to emotion and capriciousness in judging similar cases both within and across jurisdictions. They would also probably like to see a much more compressed timeframe to resolve cases so they don’t have the uncertainty and the associated stress hanging over them for years. These two issues are much more important, I think, than the potential dollar amount that might be paid out in a given claim which is largely covered by insurance anyway.

  33. Margalit Gur-Arie,

    What makes you think that it does NOT require any kind of special knowledge or skills for front-line doctors and nurses to do their job? Such nonsense flies in the face of the simple and indisputable fact that unlike doctors and nurses who work behind the scene in a back office, those of us who work directly with patients on the front-lines of care MUST have a license to do what we do. That alone should protect us from being replaced with doctors and nurses from low-wage countries like India and the Philippines. And anyone, who puts their license on the line every time they come to work, deserves a much higher rate of pay IMO than someone who doesn’t, this includes ALL healthcare workers– from top to bottom, from the top administrator down to the lowly administrative assistant– who are contributing to the outrageously high administrative costs of providing healthcare in this country!

    What do think patients and public in general believes is more important to them? Perhaps, I’m wrong, but I suspect that most, if not all, of them believe that it is far more important to have competent and well-trained doctors and nurses to diagnose, treat and care for them than it is to have so-called executive physicians and nurses to tell us front-line workers what to do (never mind that the vast majority of us already know how to do our job, and never mind that most of these executive types would fail miserably, as well as risk losing their license to practice, if they ever had to get out of their cushy office or luxurious boardroom to do our job!)

    The truth is, despite all of your efforts to make it untrue, healthcare jobs that don’t require any physical contact with patients whatsoever are at far greater risk for being off-shored than health jobs that do required physical contact with patients. The article that I cited above in a previous comment makes this point very clear. And anyone such as yourself who argues otherwise is not only clouding the truth, but is also defying logic, not to mention good-old commonsense, and thus should have no business working anywhere in the healthcare field.

    Even though I don’t know exactly what your job is in healthcare, my guess is that you are an armchair policymaker who earns a comfortable living by peddling this untruth about managerial skills being far more important than clinical skills. You and others like you do this in order to protect your own job. And because ObamaCare was crafted mostly by people such as yourself, you made sure that ObamaCare is crafted so that your job is well protected, despite how relatively insignificant and irrelevant your job is to improving patient outcome and reducing hospitalizations. This is why I’m hoping, as well as praying, that ObamaCare will prove to be a total and utter failure!

  34. Amen to that, Margolit.

    Efforts to simplify health care inevitably create winners and losers, and the sheer size of the business of health care means that lots of money will be spent by all parties to support their business model.

    We need a term for this health care model to emulate the “military-industrial complex” analogy. It applies to health care in spades!

  35. “I am sorry to be blunt, but this statement reveals that you do not have much knowledge of medical litigation over at least the last 2 decades.”

    rbaer, I think she meant physician colleagues , not paid experts. My direct experience is that fellow physicians ARE reluctant because they say, “there by the grace of god go I”.

    What system does your hospital have for peer review and oversight along with removal or retraining of a physician not attaining the proper outcomes?

  36. “then I think patients need to accept the known risks and not expect compensation is they suffer harm.”

    Barry, every medical procedure carries risk. Patients are never given a 100% guarantee yet usually there is more harm done if they don’t have the procedure. What kind of a known risk is it when you have untrained lay people trying to interpret a limited amount of technical information available to them when trained professionals can’t give the proper risk factors for any particular patient?

    Why should a patient suffer uncompensated harm if variables such as surgeon skill and surgeon experience can skew the risk. There is a risk factor in being injured or killed by a drunk driver, should those injured give up their right to sue because they knew those risks when choosing to drive?

  37. Barry,
    Regarding “evidence based guidelines”, you may want to be aware that all of those guidelines end with a disclaimer that they are not meant to replace clinical judgement and/or the need to account for new scientific development.
    Thousands of clinical guidelines exist in the AHRQ clearinghouse for every conceivable conditions, from multiple developers with multiple conflicts of interests, which are rarely stated in the guideline documentation. Many of these guidelines are conflicting. You may want to look at the new JAMA article and follow the link to the IOM report which found the state of affairs not too wonderful.
    Indeed, nothing is simple in health care.

  38. Margalit,
    this is exactly the industry talking point. It’s probably not even half true. Look at what the pharmaceutical industry spents for R+D in relation to other expenses.

  39. “and “expert physicians” are often reluctant to testify against other physicians. ”
    I am sorry to be blunt, but this statement reveals that you do not have much knowledge of medical litigation over at least the last 2 decades.

  40. Sandra_Raup –

    With respect to vaccines, I think it’s comparatively easy to show harm though it’s likely to be caused by a bad reaction to the vaccine which did not manifest in million of others who got it. The unique wrinkle about vaccines, though, is that in many if not most states, children will not be allowed to attend school unless they get their vaccinations which are intended to protect the broader population as well as the person who got the vaccine. The other part of the setup that I like is that it’s funded by a dedicated tax or fee on vaccines so the cost of compensating harm is built into the pricing structure as opposed to being one of many claims on general government revenue. Of course, the reason we have the vaccine compensation fund in the first place is that without it, no manufacturer would be willing to make vaccines for the U.S. market and subject itself to potential open ended liability. The liability risk relative to the revenue and profit potential was simply unacceptable.

    One could potentially argue that we should have a similar system for harm caused by prescription drugs. However, if the harm is caused by a known side effect in a small number of people and is included in the drug’s warning label and it won FDA approval for efficacy (vs. a placebo) and safety, then I think patients need to accept the known risks and not expect compensation is they suffer harm.

    If the patient fits a medical profile that suggests the drug should not be prescribed to that patient, that’s a different situation. However, drugs are already expensive enough. If there were a no fault compensation system funded by a dedicated drug tax, branded drug costs could be significantly higher which could create more problems than it solves. Nothing is simple or easy it seems, especially in the medical world.

    Compensating patients who suffer harm due to a failure to diagnose a disease or condition and the doctor followed evidence based guidelines in determining which tests to order or not order is a lot more problematic, I think. This is the biggest area where doctors need and should have safe harbor protection from lawsuits.

  41. Sorry – I didn’t mean to cause a big stink. Courts generally set a high bar for proving negligence (and state law also usually favors defendants because they want to keep health costs down), and “expert physicians” are often reluctant to testify against other physicians. I can’t address those cases that are settled out of court – I think that communication helps avoid litigation. Sometimes physicians and other caregivers avoid patients and families when there’s a bad outcome, and that’s right when patients and families want communication and support. I know – it’s not easy. It’s hard for everyone to get through a bad outcome, no matter why it happened.

  42. “Have you looked at the case law? Please read some cases where patients lost and tell me the courts are friendly to plaintiffs.”

    I guess you have looked at the case law and found every plaintiff successful? Have you looked at the cases that never made it to court?

  43. We already have a similar system for taking care of vaccine injury. If you think you have sustained an injury as a result of a vaccine, you must first file in Federal Claims Court in D.C., with compensation paid for from a fund set up for that purpose. It is no fault because you only have to prove causation, not negligence. If you’re unhappy with the result, you can still bring a suit in state or federal court but it’s hard to overcome the presumption that the previous findings are correct. That works pretty well as a no fault system, although I don’t know that states would approve of the federal government taking over what has been a state law issue. Something to consider – it would at least take out much of the adversarial tone because negligence would not have to be proven. I hear that 85% of sheep approve of the NZ system.

  44. Good question Steve. If you travelled across the U.S. for treatment – same question.

    My follow-up is an x-ray at 6 months electronically sent. After that I’ll find out. Emergency complications would have to be handled in U.S., like an infection.

    If I needed further surgery to correct a complication I could travel back to India, still for a lot less money than correction here.

  45. “But I’m sick of this argument and wonder if we could just get a no fault system (such as they have in New Zealand) where data can be reviewed and not hidden and the system can improve.”

    I think a no fault system is an easy concept to articulate but a tough one to execute. I don’t see any fault to compensate when doctors don’t order a test that evidence based medicine doesn’t call for and the patient turns out to be the one person out of thousands that has the diagnosis that the test might have found at an earlier stage. We have lots of rules in this country from auto safety to air and water pollution control that place an implicit (quite high) value on human life in recognition that resources are finite.

    What do we compensate people for? Lost wages? Pain and suffering? Lost companionship? What if the patient has already lived well beyond a normal lifespan and already has a compromised quality of life? I just don’t think we can compensate people for every unfortunate curve ball and vicissitude of life or insulate them from all risk. It would be cost prohibitive.

    New Zealand is a tiny country in terms of population with many more sheep than people. I don’t know how their no fault system works or how much it costs but I suspect that an American version of no fault compensation in healthcare would be far more expansive and expensive on a per person basis.

    I still think we need both sensible tort reform in the U.S. and more reasonable and realistic patient expectations.

  46. There will be no raises and no bonuses and no savings. There will be more nurses without jobs, who cannot afford insurance, cannot pay taxes and cannot properly educate their children, and therefore less money for subsidized health insurance or health care, now and in the future, which means less jobs for educated clinicians and lower salaries too, particularly since there will be a glut of job seekers.

    Keep in mind that the only jobs that cannot be off-shored are the low skilled ones, like changing sheets, holding someone’s hand and emptying bedpans. Knowledge, instructions and supervision can be, and are already being, provided remotely via video enabled computers. Be very careful when you wish for something…..

  47. Have you looked at the case law? Please read some cases where patients lost and tell me the courts are friendly to plaintiffs. But I’m sick of this argument and wonder if we could just get a no fault system (such as they have in New Zealand) where data can be reviewed and not hidden and the system can improve. Other countries do have litigation but often the incentives are changed to discourage it. For example, the UK does not allow contingent compensation for lawyers so plaintiffs have to pay their lawyers no matter what the outcome. Still, a UK physician told me that “patients like to sue if something goes wrong no matter what the cause”. I told her it wasn’t as likely to happen to her as it would be if she practiced in the US, but she didn’t believe it. So obviously it feels the same if patients have any right to file a suit at all.

  48. Perhaps you’re right, Peter, that those at the top of the healthcare food chain will simply line their own pockets with all of the savings they get from eliminating overpaid care and utilization review managers. But I’m hoping that there is enough competition in the healthcare space that they’ll reduce these and other administrative costs and then pass the savings along to patients and policy holders, as well as give out much-deserved raises and bonuses to those who provide direct-patient care, from doctors to nurses to medical aides and assistants.

  49. Barry, you want a law to determine all the facts in a case and rule in favor of the doctor or hospital without hearing evidence. I want a court to hear the evidence and determine where the fault lays.

    A wrong leg operation is never litigated in the courts, not a good example. In medicine there is usually never a clear determination of fault without examining the evidence.

  50. Peter1

    I think the disagreement between us about medical litigation boils down to two issues – how do you define a medical mistake and do you trust experts or not?

    We’re talking mainly about failure to diagnose cases in this exchange. For example, if the experts suggest that an MRI is not appropriate to order when a patient presents with a headache because there is only a 1 in 10,000 chance that it’s brain cancer and I turn out to be that one person in 10,000, I don’t think I should have justification to bring a lawsuit, period. Or, if the Preventative Services Task Force says that PSA testing is not cost effective, my doctor doesn’t order it as part of my annual physical, and I’m later diagnosed with prostate cancer, I don’t think I should be able to sue for that either.

    In the case of surgical procedures, if I’m told ahead of time that the procedure that I’m about to undergo only has a 50% success rate even when everything goes as planned with no complications and my outcome is not successful, I don’t think I should be able to sue then either. At the other extreme, if I need my left hip replaced and he replaces the right one by mistake, that’s a different matter.

    We’re always hearing about how great healthcare is in Germany, France, Sweden, Canada, etc., but they don’t have anything like the litigious culture we have. Sensible tort reform is part of the solution to our high and unsustainable medical costs, in my opinion.

  51. “The comparatively low costs as a percentage of total medical spending for both malpractice insurance premiums and jury awards don’t begin to capture the stress that doctors feel when a lawsuit is filed against them. The time it takes to provide a deposition, the lengthy period of uncertainty before the case is brought to a conclusion, the unpredictable outcome across similar cases and different jurisdictions and the threat to their personal and professional reputation is stress inducing to put it mildly. Even if no money is ultimately paid out, doctors see lawsuits as something to avoid at all costs ”

    Why should doctors feel any different, or suffer different consequences toward a lawsuit than the rest of us?

    Barry, you said the risk of not being able to sue in offshore medical facilities presents a possible problem. It seems you want the same risk to a patient here.

  52. Peter1 –

    There is a huge difference between medical mistakes / negligence and a less than perfect outcome even when doctors did nothing wrong.

    Even former Obama Administration liberals like Peter Orzag and Ezekiel Emanuel support safe harbor protection for doctors who follow evidence based guidelines where they exist. Of course, they were appointed to their positions and thus weren’t dependent, in part, on trial lawyer money to finance an election campaign the way democrats who run for elective office are.

    As far as I can tell, doctors are not likely to face failure to diagnose lawsuits when they order too many tests. So, the path of least resistance is to order more tests rather than fewer even if they are expensive and only marginally useful but don’t subject the patient to pain or discomfort. This is a big reason why we’ve seen an explosion in expensive imaging well in excess of what’s typical in Canada or Western Europe. A lot of imaging does take place in Japan but the Japanese readily accept the use of imaging equipment that is not quite as good as ours but costs far less.

    The comparatively low costs as a percentage of total medical spending for both malpractice insurance premiums and jury awards don’t begin to capture the stress that doctors feel when a lawsuit is filed against them. The time it takes to provide a deposition, the lengthy period of uncertainty before the case is brought to a conclusion, the unpredictable outcome across similar cases and different jurisdictions and the threat to their personal and professional reputation is stress inducing to put it mildly. Even if no money is ultimately paid out, doctors see lawsuits as something to avoid at all costs including ordering unnecessary or marginally useful tests that insurance will largely pay for anyway. If I were a doctor who had to practice within the U.S. litigation environment, I would practice defensive medicine too. The safe harbor protections mentioned above would, over time, make a considerable positive difference in diagnostic practice patterns, in my opinion.

  53. Cynthia, really, U.S. hospitals passing on the savings to patients. Where do you get those crazy ideas?

  54. “Worries Grow as Health Jobs go Offshore”:


    Under normal circumstances, I’m opposed to off-shoring of jobs. But if Well Point and other healthcare insurers can reduce co-pays for office visits and monthly insurance premiums they charge their policyholders by sending managed care jobs and utilization review jobs overseas, I’m all in favor of it.

    Needless to say, since there’s nothing normal, much less acceptable, about healthcare costs spirally out of control, I’m looking forward to seeing overpaid electronic paper-pushing nurses losing their jobs to modestly paid electronic paper-pushing nurse in India and the Philippines. This would also result in more healthcare dollars being freed up to pay RNs to do what they are REALLY trained to do, which to care for patients. I have yet to figure out why RNs who are employed as glorified office workers are paid substantially more than RNs who are employed as highly-skilled clinicians, especially given that they never have to deal with life-and-death issues and never have to put their licenses on the line caring for and treating patients — something which is always the case for nurses working at the bedside.

    But that’s the reality we face, ridiculous though it is. Hopefully healthcare providers will follow suit and do what healthcare insurers are starting to do, which is shipping these and other electronic paper-pushing jobs overseas. If hospitals and other providers don’t start doing this, then they’ve undoubtedly got their priorities all backwards. Listen up hospitals, as a rule of thumb, any nursing job that can be easily automated should be targeted for off-shoring, this includes overpaid jobs in nursing education and nurse administration.

    The only reasonable and justifiable argument to oppose off-shoring of care management and utilization review is that patient confidentiality would be breached. But since banks and credit card companies have managed to offshore many of their on-line services and back-office jobs without compromising banking and credit card records, then there no reason in the world why healthcare insurers, as well as healthcare providers, can’t also offshore many of their on-line services and back-office jobs without compromising medical records. In fact, I imagine that if given a choice, tough those it is, most people would choose to have their banking records secured under lock and key than their medical records.

  55. I take that to mean that by volunteering to pay inflated prices for the resulting drugs and devices, the US is effectively subsidizing innovation for the rest of the world, no matter what its origin.

  56. Agree with Barry. And:

    “While the US continues to supply much of the rest of the world with biomedical research and clinical innovation ….”
    That’s an unclear statement. If JG wants to imply that all or most meaningful research and innovation comes from the US and that there would be no meaningful innovation without the US, I would say that’s wrong (and an often used talking point of highly profitable medical corporations).

  57. “At the same time, what recourse does a patient have if dissatisfied with his care whether due to a medical mistake or serious complications?”

    I don’t know Barry, what recourse would one have here in U.S. given even you want to place more hurdles in front of patients damaged by medical error.

    Some links to Apollo Hospital for comparison to U.S. hospitals.

    The second link is in the following comment, otherwise it won’t post immediately.

  58. It looks to me like the Thai hospital’s cost advantage vs. a comparable U.S. facility is attributable almost entirely to its drastically lower pay scale across its workforce including doctors. I would love to see a comparison of differences, if any, in how much the Thai hospital pays for comparable drugs and devices vs. a U.S. facility. How much might be due to lower administrative costs thanks to their largely cash pay business model? How much relates to a less litigious environment and culture and how much to differences in operating efficiency if any?

    At the same time, what recourse does a patient have if dissatisfied with his care whether due to a medical mistake or serious complications?

    In America, if we want to reduce healthcare costs, we have the enormous challenge of changing two cultures – the medical culture of defensive medicine and the patient culture of unreasonable expectations. The latter includes everything from the expectation of an MRI for a headache just to be sure or just in case in might be brain cancer to a feeling of entitlement to even futile and wildly expensive end of life care which someone else is expected to pay for.

  59. “Americans don’t want any of that. Americans want jobs here to do all that for themselves, jobs that pay enough to afford all those things and services.”

    What about jobs moving from the union north to low wage non-union south? What about union members shopping at Walmart? What decisions will Americans make when the next guy can do it cheaper and they have their own dollars to spend, even when they are losing their own job to overseas low wages and low regulations?

    I agree with you Margalit but Americans never vote that way, either politically or economically, they vote for low prices.

    I wasn’t going to lay on my economic sword for high priced medical care here when no one else really cares (or has to) AND they’re getting subsidized care. GIVE ME A SUBSIDY AND I”LL GET MY CARE HERE AS WELL!

  60. “Americans want their goods from overseas. They want their accounting from overseas. They want their engineering from overseas. They want their IT from overseas. Why not their medical care?”

    Americans don’t want any of that. Americans want jobs here to do all that for themselves, jobs that pay enough to afford all those things and services.
    This short-sighted strategy is crippling this country and is driven by corporate profit seeking, and there is very little Americans can do about it. We are collectively shooting ourselves in the foot. Hopefully they can treat that overseas too….

  61. My care experience was great! As was my hotel and resort experiences. But you need to be open to a different cultural experience – especially outside the hospital or hotel.

    If Medicare or Medicaid started offering overseas medical care to save money I bet there would be political lobbying to ban the option as it would truly be a market based solution – the worst nighmare for U.S. medical care.

    Americans want their goods from overseas. They want their accounting from overseas. They want their engineering from overseas. They want their IT from overseas. Why not their medical care?

  62. Choosing India or Bumrungrad is no different than choosing a U.S. facility or physician – do your home work. What happens when you want a competent surgeon/hospital who is not covered because he’s out of network?

    For my particular operation (resurfacing) there are too many U.S. surgeons who should not be doing this operation (at least with their present skills) and the results can be catastrophic.

    Patients should not be going into these decisions because they think a law suit will solve their mismanaged surgery, they should be doing it because a law suit will not be necessary. Just because a law suit can be handled by a contingency fee does not mean you will be successful in winning anything close to what you should be compensated for, especially since many states have enacted doctor friendly protection laws.

  63. DIdn’t ask but strongly suspect that physician fees/comp are comparatively lower as well, as are their practice expenses, which would include malpractice. So far, they have not caught our tort liability disease.

  64. And if you’re looking for where the competitive heat will come from for Bumrungrad and the Middle Eastern competition, it’s from India.

    How was your care experience in Chennai?

    And for the question you begged, how long before Medicaid programs in high cost states look at the numbers and begin offering their patients the option of traveling to India for care.

  65. So that’s what happened to Mack Banner. Nice piece, Jeff. Interesting that you focus on the cost of nursing labor in the context of overall costs -> pricing. Are physician costs also running at what look like 20-30% of US rates? And to what degree to do you think what I assume is a different med/mal component keeps cost -> pricing so much lower?

  66. With the imposition of the draconian legislation of the PPACA mandate, and a growing wave of aging seniors retiring – the surge to expat out and that group needing care should surpass the ‘accidental’ tourist; and quickly.

  67. ” A total joint replacement (hip or knee), including diagnostic tests, all physician fees and hospital care, can be done at Bumrungrad for around $16 thousand.”

    My hip resurfacing at Apollo Specialty Hospital in Chennai India totaled $10,000 which included airfare, hotel and all hospital/doctor charges. Better infection control outcomes than U.S. and British trained world class surgeon.

    For elective there are alternatives for uninsured or under insured or for those not covered for anything other than in-network and who want a top surgeon specialist for their case.