December 13, 2022
Dr. Brown explains two types of Medical Tourism and the reasons behind each. She describes the pros on cons of traveling across the border to Tijuana or other cities in Mexico to seek Bariatric Surgery. She tells stories from taking Bariatric emergencies that will help you think longer and harder about making the trip.
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Medical Tourism is traveling outside of your geographic location to obtain surgery. This is a common occurrence in bariatric surgery and is mostly driven by cost. When we talk about medical tourism, there are two types of medical tourism.
Firstly, there’s the type of medical tourism where you travel within the United States to another state or geographic location. I don’t think this is a necessarily negative type of tourism and is often motivated by patients either trying to locate an expert in the field that is not geographically available to them, a hospital system that may offer more resources than what they have locally or a referral by a friend or family member.
This type of medical tourism can be suitable as long as a couple of things are met. So if you’re looking to travel outside of your geographic location but within the United States for surgery, I would recommend that you ask a few questions. I would start by asking, how often do you treat patients outside of your geographical area? If you treat them often, what is the protocol for preoperative evaluation, Postoperative evaluation, and long-term care? Are you interacting with a surgeon that is going to take care of you via telemedicine? Are you interacting with support staff? Have they done a complete physical and history on you so that they can ensure that the procedure that you’re having done meets all of your specific medical needs? When I talk about post-operative care, who are you following up with? How frequently are you frequently?
Are you following up with that person, person and what are they providing you? Now, do they have online modules? Do they have tele-visits or online videos? That’s important when you travel for surgery. If you have a complication, do you or have you identified a surgeon in your geographic location that even feels comfortable with the surgery that you’re having performed? Suppose you’re traveling outside of your surgical area for a surgery that isn’t readily performed there. In that case, you may have a difficult time finding post-operative care that is suitable or finding someone to take care of you if God forbid you have a complication because they simply may not feel comfortable caring for you because they’re unfamiliar with the surgery that you had done. So those are important questions to tease out. If the deferral is that your primary care physician will manage your vitamins and check your labs, make sure that you have that conversation with your primary care physician first to ensure that your primary care physician is on board and comfortable managing that postoperatively as not everyone will be.
And lastly, for nutritional support for the remainder of your life, are there tele-options? Are there local nutritionists that are available, et cetera? So setting yourself up for success to ensure that you either have remote telemedicine or local care, preoperatively and postoperatively, is going to be paramount to ensure that you’re safe and you’re successful.
If you travel within the United States to arrive at surgery more quickly… I caution against that for a few reasons. You will see providers that advertise one day to surgery or four days to surgery. When you look at these programs, something to keep in mind is that bariatric surgery is a complete lifestyle modification, preoperatively and post-operatively, for life, and the support that you receive before and after surgery can really determine your long-term success. If you’re traveling to a provider offering you same-day surgery, have they taken the opportunity to get to know you medically to ensure that you’re having the right procedure and that you’ll be supported after surgery?
Many of the evaluations that we recommend as surgeons are recommended so that you can be successful and safe after surgery. I find that my patients who undergo nutritional counseling before surgery and truly understand the diet, the lifestyle modification are more successful long-term. So when you see providers offering rapid surgery with no requirements, I do recommend that you at least give pause, ask some questions, and ensure that you are making a decision that you know can be sustainable and can allow you to be successful.
You’ve heard every provider say surgery is a tool, it is not a silver bullet solution.
So you have to ensure that surgery is combined with the appropriate support system.
Now let’s talk about international travel. Many people travel internationally for surgery, specifically bariatric surgery, for cost reasons. When we talk about cost, the first and most important thing I ask you to do as a patient is to check your benefits.
Many people do not think they have bariatric benefits when they actually do. Less than 1% of people who are eligible, eligible for bariatric surgery receive bariatric surgery. So number one, I want you to go to your insurance company and ensure that you don’t have bariatric benefits before you travel somewhere else.
The out-of-pocket cost will be copays and deductibles if you have bariatric benefits. If you don’t have bariatric benefits, your next step is to talk to your human resources department and ask, are bariatric benefits available and you didn’t choose them? If you didn’t choose them, you may have the opportunity to upgrade during open enrollment to have your bariatric surgery covered. If you don’t have bariatric surgery benefits, your next step should be to look at the cost of a cash-pay bariatric surgery in a direct geographic location or within the United States.
Many programs in the United States offer comparable prices. While I can’t speak to the prices at other institutions, our institution can offer a sleep gastrectomy for less than $10,000.
Now, what does that include? That includes your pre-op visit with your surgeon. It includes your preoperative laboratory values, your psychology visit, three nutrition visits, and a lifelong support system. A lot of the time, when you see a low price point across the border or in another country, what you’re seeing is the price of surgery alone. That doesn’t include anything else, including travel or lodging. So when you actually get down to the brass tax of the cost of the surgery as a whole, you actually may find that the price inside the United States is equivalent or close enough to have you make that decision to stay in the United States for safety reasons.
Now, this is an important conversation to have when I talk about safety.
It is not that there aren’t good surgeons in other countries. Absolutely unequivocally there are good surgeons in other countries, and certainly, most people can say that they know somebody that traveled to another country to have surgery and had a great outcome.
Those outcomes do exist.
But what I can say is that when you talk about international travel, the standards of care and safety standards are not the same as in the United States. Speaking for a center of excellence for bariatric surgery In Arizona, we are evaluated repeatedly and frequently for patient outcomes, the number of cases, the breadth of cases, meaning how many different surgeries we offer, what our outcomes are, and we are required to submit every single complication that comes through our institution. And every one of those complications is reviewed by an independent reviewer, and each surgeon is individually reviewed at intervals to ensure that the patients are receiving the safest and most effective care possible.
Additionally, training requirements may be different in other countries.
I have heard some stories of dentists operating on patients for bariatric surgery or gastroenterologists offering bariatric surgery. People who are well in their own right, are very qualified to perform the professional services they’re trained to do. But they can’t perform surgery because they decide to.
I have heard those stories, and that’s not a situation that I ever want to find a patient that comes into our emergency department.
There also may not be any follow-up when patients travel abroad. It is often a once-and-done deal, and what you may find is that you may not have the optimal outcome or the optimal weight loss after surgery. You may find yourself with questions and concerns where you have no one to reach out to answer those questions. Or you may find yourself with a medical complication that either a surgeon in the United States is not able or willing to care for or the insurance company may not cover.
In a few minutes, I’ll tell you a story about a patient who had an unfortunate outcome, and their insurance company did not pay for the complication related to that surgery because that surgery was performed in another country.
And then lastly, you may not be getting the surgery that you think that you are getting, or you may not be getting a surgery that is readily performed in the United States that can be cared for by a surgeon that is here.
So what I’d like to do is tell you a few stories.
These are certainly not the only stories that we have. With Arizona being as close to Mexico as it is, we do see a fair amount of complications.
One of the most common complications is leaks from the staple line or the connections. As someone who takes bariatric surgery emergency calls, I see these much more frequently than I should be coming from other countries. Unfortunately, there are situations where the insurance company will not cover that complication.
So my first story talks about a patient who came to the emergency department for a gallbladder problem. That patient had nothing to do with her bariatric surgery. However, I was the surgeon on call that day and took her to the operating room. And we saw that the patient, who had reportedly undergone a sleeve gastrectomy, had never had any surgery. She had incisions on her abdomen that were consistent with bariatric surgery, but on the inside, nothing had changed. When later questioned, the patient reported that she had roughly 30 pounds of weight loss overall but regained the weight, which would mostly be attributed to her dietary change after surgery. Unfortunately, that patient had no recourse with the bariatric surgeon she had gone to see because she paid cash and it was in another country.
My second story is a miserable story about a young lady who traveled to Mexico to have her lap band removed. The reason that she had traveled there was that several of her friends or family members had had a good experience with this surgeon.
On postoperative day one, she complained of 10 out of 10 abdominal pain.
Unfortunately, she was still sent home.
She arrived in our emergency room very sick. A CT scan showed that she had a leak in her stomach. When I took her to the operating room due to the extensive contamination, unfortunately, I had to make an open incision. I saw a quarter-sized hole in her stomach. While this was startling in its own right, the more startling portion of this was that the hole was surrounded by haphazard stitches that clearly showed that the surgeon in the other country had attempted to repair it and had not told the patient that there had been a complication and sent the PO patient home anyway in the setting of 10 out of 10 abdominal pain.
Fortunately, the long-term outcome of this patient’s story is a positive one with a full recovery.
However, she did spend nearly a month in the hospital, underwent multiple procedures, and was on IV nutrition for approximately three months with nothing to eat or drink in an attempt to adequately heal the repair that we had performed.
Additionally, her insurance company did not cover the cost of the complication, and unfortunately, the patient was responsible for roughly $200,000 out of pocket. This can be a debilitating cost causing bankruptcy for patients.
And this is something to consider when deciding to choose surgery in another country because nobody can anticipate the outcome of that surgery, even a surgeon in the United States. If that surgery is performed in the United States, your insurance company will cover that complication.
And then lastly, I want to talk about a patient who had a gastric balloon placed. The patient went to Mexico to have the gastric balloon placed because they were not affordable in the United States for her.
She had had previous surgery in the past that would have, in the United States, prevented her from having the balloon placed for the risk the balloon would travel into her intestine. But the surgeon in Mexico did not consider this and placed the balloon anyway.
She presented to the emergency department with significant abdominal pain, originally thought to be her gallbladder. A CT scan revealed an in-place gastric balloon when gallbladder disease was ruled out. However, the tubing was still connected to the balloon. So let me backtrack a little bit. When you place a gastric balloon, the patient swallows it, and a tubing connected to that balloon fills it up so that the balloon can occupy space in your stomach. That tubing is then disconnected and removed from the stomach. It is not left in place.
In this situation, the tubing had been placed and had traveled into her small intestine, potentially causing a life-threatening bowel obstruction. I think the most important part of this story is that the person who placed the balloon had not had adequate training to place those balloons and put the patient in a situation where not only did she have a procedure that in the United States, she would’ve never been able to have done due to the high risk of her prior surgery, but most importantly was performed incorrectly and put her at risk for a complication that she should never have been at risk for.
Fortunately, the patient was referred to gastroenterology, and the outcome was positive.
I tell you these stories simply because we see them daily, and our goal is to protect our patients. I think that when people are in a position where they don’t feel they can receive care for cost reasons in the United States, that is a terrible position. So what I urge you to do, if you find yourself in a position where you’re deciding to travel for surgery, is do the research, ask the right questions that we discussed in this podcast, and ensure that you do not have benefits because you may have benefits that you’re not aware that you have.
And reach out to surgeons in the United States to answer some questions before you make a decision that could change the rest of your life.
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