Skip directly to content

A Venture into Medical Tourism: Why Our Health Care System Needs to Adapt

on Tue, 08/23/2011 - 01:01

By Lloyd Baron, Ph.D.

August 2011

 

In the October 2 2010 issue of the Vancouver Sun (pg. A12-13), the article “Meet Jack the surgical robot, on the edge of prostate cancer treatment” by Pamela Fayerman, showed that the continuation and expansion of robot-assisted laparoscopic surgery in B.C. is threatened by inadequate funding and training, less than optimal usage, and a proposed fee structure for usage by patients that broaches a whole discussion on equity in the delivery system. It explored the challenges facing the British Columbia health care system as it struggles to update both practices and viewpoints. Fayerman wrote, “With advances in newer and better technologies during a time of shrinking resources, health professionals and policy-makers around the world struggle with the questions of who should pay for expensive technology that can improve patient outcomes, albeit only slightly, compared with conventional treatments.”

Unless the Province of British Columbia introduces a strategy to systematically address this fundamental dissonance in our health delivery system, B.C. [...] may be forced to outsource an ever-increasing array of advanced medical services in order to satisfy local demand for excellence.

The example cited above is not unique; it represents a case study for a growing challenge that our health care system must address. The excellence in our advanced medical delivery system is increasingly compromised by accelerating costs of innovation that must compete with budgetary considerations that have, as a primary mandate, the provision of universal care. Unless the Province of British Columbia introduces a strategy to systematically address this fundamental dissonance in our health delivery system, B.C. will, in specific areas, gradually lose its ability to provide the best possible outcomes to its population from local resources and may be forced to outsource an ever-increasing array of advanced medical services in order to satisfy local demand for excellence.

A world-class universal medical deliver system that is totally provincially funded will become increasingly untenable with a relatively small population base that cannot support major innovations financially on a sustainable level.

What must be done about this? The Province must develop a strategy for earning additional out-of-Province revenues. These revenues will be earned by selling our resources in the world marketplace at the research, teaching, and clinical levels. A business strategy must be developed that recognized that the globalization of the medical industry will be a significant transformation force over the next generation. Our autarchic, provincially-sealed system will not be able to provide both universal care and, at the same time, guarantee world-class excellence in all specialties and sub-specialties. A world-class universal medical deliver system that is totally provincially funded will become increasingly untenable with a relatively small population base that cannot support major innovations financially on a sustainable level. We have centres of excellence that can be marketed outside our Province and simultaneously have medical professionals and facilities that are constrained by budgetary considerations from optimal levels of utilization.

As an economist and a long-term resident of British Columbia, I have had both unique profession and unique personal experience with our medical delivery system and with the rapidly transforming medical delivery capacity of specific countries.

Professionally, I was founder and president of Canadian Advanced Medical Services International (CAMSI). Funded by the faculty of medicine at the University of British Columbia and the five teaching hospitals of the Lower Mainland, CAMSI was, in the mid-1990s, able to achieve some remarkable results when we matched the Province’s advanced tertiary and quaternary medical research, teaching, and clinical capacity with the world’s population needs. Many concrete revenue-generating projects were implemented and significant revenues were earned. Projected revenues exceeded the development costs.

However, in the third year of development, we hit a wall of resistance that was insurmountable. The project was caught in the vice of budgetary constraints. In such an environment, it was difficult for the administrators to justify any investment in the future while there were insufficient funds to meet present needs. Overnight, CAMSI was transformed from a promising revenue-generating initiative into a simple cost centre that had to be cut back. Faced with these challenged, our team chose to direct our energies elsewhere and we moved on to other projects.

Personally,  I was diagnosed with Osteoarthritis (OA) in my left hip and referred to a specialist in 2010. For the second time, I elected to seek major medical interventions outside of the Province for a procedure that has not, for a variety of reasons, been perfected in the Province. On both occasions I acted upon the advice of local surgeons when it was clear that choosing a local solution would have exposed me to unnecessary additional risk.

I joined the growing force of medical tourists looking for solutions abroad.

Consequently, I joined the growing force of medical tourists looking for solutions abroad. After being diagnosed with OA, I was fortunate to get a consult with a specialist in five weeks. I was informed that if a surgical procedure was recommended, it would take anywhere from six to nine months to undergo the scheduled operation. My pain, at that point, was already constant and I was facing dramatic limitations to my active lifestyle.

I first approached the private service providers in Vancouver. I was informed that I could get a specialist consult; however, the cost would be $1000 and I would still have to wait several weeks. In the final analysis, the private consult would not help since I would still be forced to join the queue; hip surgery is not permitted in the private sector within B.C.

I was able to get a consult over the internet from one of the world’s leading orthopaedic surgeons within 24 hours, without cost. After reviewing my x-rays, sent via my mobile phone, Dr. Bose informed me that I was an excellent candidate for a hip resurfacing procedure.

I began to search for solutions outside of the Province and was surprised at the range of alternatives that were immediately available. In the first instance, I was able to get a consult over the internet from one of the world’s leading orthopaedic surgeons within 24 hours, without cost. After reviewing my x-rays, sent via my mobile phone, Dr. Bose informed me that I was an excellent candidate for a hip resurfacing procedure. A little more research revealed that my hip could be resurfaced within several weeks at a wide array of excellent facilities in the United States, Europe, and Asia at a cost that ranged from $7500 to $35000. I could receive surgery, be relieved from my pain, and on the path to complete recovery and a return to active life even before the time a first B.C. medical specialist consult could be arranged.

I could receive surgery, be relieved from my pain, and on the path to complete recovery and a return to active life even before the time a first B.C. medical specialist consult could be arranged.

To add insult to injury, because B.C. restricts orthopaedic procedures, our specialists are falling behind in their proficiency in some areas. For example, there is not one surgeon in B.C. who has performed more than 50 hip resurfacing procedures, while the leading orthopaedic surgeons in the global arena have performed over 1000 operations each, with some as many as 3500. The literature posits that it takes up to 100 operations to perfect the hip resurfacing procedure. Even if a B.C. surgeon and a hospital were immediately available, I would be exposing myself to additional risk if I chose the B.C. alternative. My choices to be a medical refugee was both logical and definitive. I bore the additional financial costs because I could – but what about thousands of others in need?

My choices to be a medical refugee was both logical and definitive. I bore the additional financial costs because I could – but what about thousands of others in need?

From a very cursory search on the internet,  I found two interesting anecdotes that mirrored my situation. There are seven men from Golden, B.C., who have recently ventured to India to have their hips resurfaced because there is no OA specialists in the area who can even begin to address their needs (search for “Jeff Dolinsky the Golden Hippy” on YouTube). There is a firefighter from Victoria, Rob Beillar, who could not wait for the surgery due to his active job. He was back on the job in three months after a successful out-of-Province operation. These patients represent a growing trend. Although I do not know how many are making the same decision as I did with reference to hip problems, I would venture to say that the number is ever-increasing.

There is a global market for medical procedures and we are not in that market.

Our approach to rationing medical services does keep the costs down; however, it has, in some cases, deleterious externalities that force our medical delivery system away from the cutting edge (no pun intended). Our obsession, for example, to bar any foreigner from systematic access to our system is resulting in enormous lost opportunities to earn significant revenues from the export of our medical expertise (just as university students receive in-province subsidies and universities incur greater revenue from international students). There is a global market for medical procedures and we are not in that market.

And while we build the Maginot Line around the containment of a two-tier system, the world passes up by. Instead of being technological leaders, we are often relegated to the backwaters as late-adopters.

At CAMSI, we initiated several important export programs that earned our medical services significant additional revenue. We proved that there was massive, untapped potential for developing our underutilized medical expertise in the international market; this was obvious, for example, in B.C.’s cancer (BMT) and cardiac (stents) sectors, which had potential to become world centres for care in those areas.

I am certain that not much has changed. We still expend large amounts of public funds training medical practitioners in a range of specialities and sub-specialties and then force those in certain specialities to work part-time. This is an egregious misallocation of resources. And while we build the Maginot Line around the containment of a two-tier system, the world passes up by. Instead of being technological leaders, we are often relegated to the backwaters as late-adopters.

Unable to even clear the waiting lists for older procedures, why should our specialists divert energy for a newer process that requires additional training and is more technically challenging to execute, only to learn that they cannot expand their practice globally?

For example, in the area of hip-resurfacing we missed an enormous opportunity. It was only two years ago that the U.S. Food and Drug Administration (FDA) approved the procedure for the world’s most popular implant. In Europe and Asia, specialists have been treating thousands of patients for more than ten years using an implant developed in England. Had we entered the field at the earliest stage of adoption we could have invited U.S. patients to get their hips resurfaced here in B.C. We would have treated as many as 10000 patients from the U.S. alone prior to the FDA’s approval of the procedure. Assuming each process would have cleared us a surplus of  a modest $10000, it would have garnered for our system $100 million from this one procedure alone over those ten years. Not only would the whole system have benefited financially, but we would have removed the waiting list entirely for all hip replacements and would have positioned ourselves as the unassailable global leader in the field. What resulted is a procedure that is not expanding exponentially everywhere by here, and we will never be able to catch up. While we continue to concentrate on more traditional, older technologies (like total hip replacements), new growth industries are passing us by (such as hip resurfacing procedures). Unable to even clear the waiting lists for older procedures, why should our specialists divert energy for a newer process that requires additional training and is more technically challenging to execute, only to learn that they cannot expand their practice globally?

Maintenance of the policy of universal health care, which is a boon to all citizens, is not threatened if we alter the strategy intelligently. In fact, it can be made stronger, more resilient, and more sustainable.

I am disappointed with our province. We have pockets of medical excellence that are being starved. We can compete globally (an alien concept in our medical delivery system) and we can earn additional revenues from the export of selected tertiary and quaternary procedures. With the surplus earned we could feed the whole provincial medical delivery system. Maintenance of the policy of universal health case, which is a boon to all citizens, is not threatened if we alter the strategy intelligently. In fact, it can be made stronger, more resilient, and more sustainable.

Our medical delivery system is being challenged not only by long and growing queues as our population ages, but by an international market in which we refuse to engage. The consequences for our local delivery capacity are dire.