I reside in Asia and have been using Bumrumgrad hospital for my family healthcare needs for over 6 years now. I have been featured in a CBS special on Bumrumgrad roughly 5 years ago.

The article is hits on some points as well as the discussions. Thank you to everyone who has been involved in this dialogue.

If there is a lack of understanding of how Asian Medical Tourism or Healthcare is being reinvented and the focus is primarily on affordable labor I recommend a visit to these various hospitals.

It is not only affordable labor but the lack of a lawsuit and insurance mentality that makes it affordable. Also..the cutltural way of dealing with health creating an integrated medical approach with higher efficacy that is inviting.

The experience is like no other in the world….it is truly a positive colorful expedrience rather than a scary, white sterile, lawsuit laden, insurance driven machien that creates a horrible experience for the patient.

Again..I recommend visiting these places and then a greater udnerstanding will be found.

Best,
Sheldon

All excellent points and we seem to be converging on agreement. My only final point would relate to this exchange:

Looked at another way, if the goal is to maximize the health outcomes of individuals, then, absolutely, best available, most expensive option, will win out. But, if the goal is to maximize the health outcomes of a community, then an option which is cheaper but still effective, is sometimes better than the expensive, high-tech option.

I WOULD ARGUE THAT THE INDIVIDUAL OPTION WHICH MAXIMIZES BENEFIT/COST RATIO FOR THE INDIVIDUAL WILL ULTIMATELY ALLOW THE APPROPRIATE ALLOCATION OF RESOURCES ON A MACRO LEVEL TO MAXIMIZE BENEFIT/COST RATIO FOR A COMMUNITY…SUBJECT TO YOUR EXCELLENT POINTS ON CONTEXT, AFFORDABILITY AND ACCESS.

Tej

MY ISSUE HERE IS THAT WE DON’T KNOW WHETHER IT SUBSTANTIALLY IMPROVES OUTCOMES OR NOT. YOU ARE ASSUMING IT DOESN’T.

I am not assuming that it does not. Rather, I concede that it might improve outcomes, and, personally, I tend to believe that it does. But, I do believe that the ‘bang for the buck’ is extremely weak as evidenced by soaring healthcare costs in the United States, which are driven in large part by technology (as well as doctor’s, and hospital’s fees), and far outpace patient outcomes. The literature on this relationship is strong.

Looked at another way, if the goal is to maximize the health outcomes of individuals, then, absolutely, best available, most expensive option, will win out. But, if the goal is to maximize the health outcomes of a community, then an option which is cheaper but still effective, is sometimes better than the expensive, high-tech option.

THE ONLY WAY WE WILL TRULY KNOW THIS IS TO MEASURE THE VARIOUS OUTCOMES AND THEIR RELATIVE COSTS AND OPPORTUNITY COSTS.

This is true, but it also holds the same implications for both your and my argument.

A PARTICULAR TREATMENT PROTOCOL MAY COST MUCH MORE UP FRONT BUT MAY SAVE $$ IN THE LONG RUN. THERE IS NO WAY OF DETERMINING RELATIVE COST BENEFITS UNLESS OUR STUDIES ARE ACTIVELY LOOKING AT THIS ISSUE.

True. But, this is not, for me, the central issue. The central issue is creating treatment options that open up the health system to the greatest number of people. In a healthcare context where a majority of the population is unable to pay for even rudimentary healthcare at the lowest possible price, treatments above a certain price level cease to make sense.

MY VIEW ON THIS POINT. I FIND IT VERY HARD TO BELIEVE AND WOULD LOVE TO SEE THE ACTUAL STUDIES WHICH PROMOTE THIS TYPE OF SURGERY BEING DONE WHILE PATIENT IS AWAKE. THE ISSUE IS TO AGAIN EVALUATE THE DIFFERENT METHODS OF OPEN HEART SURGERY, THE RELATED COMPLICATION RATES, THE OUTCOMES, AND TO DO IT METHODICALLY. I HAVE TROUBLE WHEN THE ECONOMIST ENGAGES IN THIS KIND OF PROMOTION WHICH PURELY SUPPORTS AN ARGUMENT THEY ARE TRYING TO MAKE IN AN ARTICLE.

You will find no counter argument from me as far as the Economist’s motivations go. The author of that particular article is more bias than most.

But, this does not eliminate the fact that the Indian surgeons mentioned in the article are trying to adapt their practices to their own healthcare context; one that requires a procedure which is both faster and cheaper than the one used in the United States. This sort of attention to cost is something that you and I appear to agree is an important effort to make.

If, as may be the case, the outcomes of this particular procedure are not as successful than a more orthodox procedure which requires anesthesia, its accessibility and cost may still carry more weight and lead to it being more readily accepted as a procedure of choice. Though, I agree, buyers should be aware that the dangers might be higher (though, this is a general rule with healthcare that should always be followed, especially when accessing healthcare in an unfamiliar environment).

Maybe this leads to a broader point about there being no singly ‘universal ideal’ of healthcare. While I believe that there are certainly lessons that can be shared between any two particular healthcare contexts, it does not follow that every lesson from one context will transfer into the other.

I would certainly never want to claim that, for example, open heart surgery with the patient still awake is the best way to perform that particular surgery. But, it could probably be argued that it is a better way to perform the surgery in some healthcare contexts.

Maybe, it is this last point that drives to the heart of our disagreement. The GM-Asia story by Mr. Toral should not be intended to mean that anyone coming into Asia should adapt Asian ways, completely retool their entire operation, and then bring that operation back home.

Instead, it should serve to show that the Asian context is different than the American context, and that by creating an organic business strategy a business can find new ways to reinvent itself in a way that would not be possible otherwise. In turn, this sort of reinvention could help the business innovate in other ways within its context of origin (The USA if you are GM), by shifting the company culture in a direction that causes a rebirth of a innovation. It does NOT mean, however, that the details of a business’s structure should necessarily be transferred in their entirety or otherwise from the new location to the old.

Fair enough.

Why spend a million-plus dollars on some new technology if it does not substantially improve health outcomes for a substantial number of people and other options are available?

MY ISSUE HERE IS THAT WE DON’T KNOW WHETHER IT SUBSTANTIALLY IMPROVES OUTCOMES OR NOT. YOU ARE ASSUMING IT DOESN’T. THE ONLY WAY WE WILL TRULY KNOW THIS IS TO MEASURE THE VARIOUS OUTCOMES AND THEIR RELATIVE COSTS AND OPPORTUNITY COSTS. A PARTICULAR TREATMENT PROTOCOL MAY COST MUCH MORE UP FRONT BUT MAY SAVE $$ IN THE LONG RUN. THERE IS NO WAY OF DETERMINING RELATIVE COST BENEFITS UNLESS OUR STUDIES ARE ACTIVELY LOOKING AT THIS ISSUE.

For that same reason I cannot agree that Asia has nothing to teach America. It absolutely does. From technical skills – open heart surgery in India is being performed while the patient is still awake because it speeds up recover times;

MY VIEW ON THIS POINT. I FIND IT VERY HARD TO BELIEVE AND WOULD LOVE TO SEE THE ACTUAL STUDIES WHICH PROMOTE THIS TYPE OF SURGERY BEING DONE WHILE PATIENT IS AWAKE. THE ISSUE IS TO AGAIN EVALUATE THE DIFFERENT METHODS OF OPEN HEART SURGERY, THE RELATED COMPLICATION RATES, THE OUTCOMES, AND TO DO IT METHODICALLY. I HAVE TROUBLE WHEN THE ECONOMIST ENGAGES IN THIS KIND OF PROMOTION WHICH PURELY SUPPORTS AN ARGUMENT THEY ARE TRYING TO MAKE IN AN ARTICLE. MAYBE THEY SHOULD PROVIDE THE ACTUAL REFERENCES TO THE MEDICAL LITERATURE WHICH SUPPORTS THIS KIND OF TREATMENT PROTOCOL. AND IF IT DOESN’T EXIST AND INDIAN PHYSICIANS ARE SIMPLY “WINGING IT” THEN BUYER BEWARE.

Health IT infrastructure – America is only now starting to get a handle on things; and hospital management philosophy – in truly innovative hospitals, there are a lot of doctors and administrators figuring out the key problem of their lot which is how to deliver high quality care to a large number of people.

AMERICA HAS LONG UNDERSTOOD THE PROBLEM. VESTED INTERESTS AND PROVIDERS HAVE CREATED AN INERTIA RESISTANT TO INNOVATION. AND HERE IS WHERE ASIA CAN DEFINITELY LEAPFROG.

Perhaps my point in the article was not as clear as I thought it to be. Two of the points you mention, are actually two of the points I was trying to make;

1.)” I personally feel the advantages in Asia you describe are simply exploitation of labor wage differentials in openly trading markets and a growing consumer/middle class in Asia as a result of Asia adopting adapted versions of capitalism from western developed countries.”

and

2.) This is a disaster in the making. See “Trust me…I’m a doctor” on Clearstate’s blog. When physicians have financial interests in procedure volumes, kick backs from laboratories, and other financial conflicts of interests, then who really know whether “economies of scale” volume is driven by the patient’s best interest or the doctor’s desire to own a BMW.

I was hoping that my mention of Bumrungrad and the context I put it in would get the latter point across – I do, in fact, state in different words that access there is very limited. I mention Apollo Hospitals as an example, because it is a well known hospital group and this helps the average reader
get a better grasp on an analogy.

As for the first point, I have made it numerous times in this blog, though I did not explicitly state it here. I hoped that it would be contained between the lines of what I was saying, but I will admit that it could have been clearer.

It’s also interesting that you point out that the Economist article – while on the plane back to the United States I spent about three hours critiquing it for various flaws…but, the idea that successful health systems can be created using lower-cost technological solutions stuck with me. Why spend a million-plus dollars on some new technology if it does not substantially improve health outcomes for a substantial number of people and other options are available?

For that same reason I cannot agree that Asia has nothing to teach America. It absolutely does. From technical skills – open heart surgery in India is being performed while the patient is still awake because it speeds up recover times; Health IT infrastructure – America is only now starting to get a handle on things; and hospital management philosophy – in truly innovative hospitals, there are a lot of doctors and administrators figuring out the key problem of their lot which is how to deliver high quality care to a large number of people.

Other than “the Asian health market is a perfect testing ground for American healthcare leaders to come and build lighter and more innovative hospital systems.” I am unclear as to what within the Asia experience of delivering healthcare has been so innovative. Building shiny new hospitals that caters to tourists or wealthy is hardly innovative. The so-called “delivering on quality” is typically being done by opportunistic and entreprenuerial American trained physicians who see $$$ in coming back and establishing delivery facilities in a young cash paying fee for service environment. Nothing innovative about that. That’s the American way.

All if not most innovations within healthcare whether it be technological diagnostics/treatment options or delivery options have originated in North America or Europe. The delivery systems were not built like a Hummer;they evolved to be this way for several reasons one of which being an attempt to spread risk and coverage amongst as many as possible. Asia can benefit by avoiding some of the pitfalls that are preventing further innovation in America but there is not much America, at this point at least, can learn from Asia.

I personally feel the advantages in Asia you describe are simply exploitation of labor wage differentials in openly trading markets and a growing consumer/middle class in Asia as a result of Asia adopting adapted versions of capitalism from western developed countries. In other words the playing field is not level and Americans/Europeans are competing with one hand tied behind their back (due to high labor costs structures, unions etc). You speak to the Bumrungrad and Apollo systems briefly but access to these fine institutions is pretty limited. Most of our typical middle to lower class Asians will not be able to access even a fraction of what a Medicaid/Medicare patient can from a basic community hospital in the U.S. This why despite medical tourism which not intended to source out more innovative or quality physicians/hospitals but is simply a profit maximizing activity by insurance companies, goes both ways. Truly wealthy Asians still go to the U.S. for complex medical issues for a reason.

The Economist

“New competitors are also emerging. A recent report from Monitor, a consultancy, points to LifeSpring Hospitals, a chain of small maternity hospitals around Hyderabad. This for-profit outfit offers normal deliveries attended by private doctors for just $40 in its general ward, and Caesarean sections for about $140—as little as one-fifth of the price at the big private hospitals. It has cut costs with a basic approach: it has no canteens and outsources laboratory tests and pharmacy services.

It also achieves economies of scale by attracting large numbers of patients using marketing. Monitor estimates that its operating theatres accommodate 22-27 procedures a week, compared with four to six in other private clinics. LifeSpring’s doctors perform four times as many operations a month as their counterparts do elsewhere—and, crucially, get better results as a result of high volumes and specialisation. Cheap and cheerful really can mean better.”

If we really stop to examine this paragraph. This is a disaster in the making. See “Trust me…I’m a doctor” on Clearstate’s blog. When physicians have financial interests in procedure volumes, kick backs from laboratories, and other financial conflicts of interests, then who really know whether “economies of scale” volume is driven by the patient’s best interest or the doctor’s desire to own a BMW. And knowing many doctors in Asia..the answer is not hard to find.

Anyway, I ramble. Getting back to you final point which I agree with, the true innovation that Asia can grasp with the help of American innovations in I.T. is the digitalization of health records and the entire medical experience. Only then will we be able to measure true cost effectiveness of treatments with respect to outcomes and only then will any country be able to effecticely deliver the highest quality of care to the most of its citizens at sustainable costs.