Wednesday, November 12, 2008

Medical Tourism, Self-Insured Employers, and Medical Ethics

Wellpoint, which provides health insurance to 35 million, is starting to pilot medical tourism. The initial numbers are small - Serigraph, a self-insured printing company in Wisconsin, with 700 employees.

But when an elephant puts a toe in the water it's big news! (Elephants actually have toes, but they're inside their feet.)

The pilot allows patients to go to hospitals in Bangalore or Delhi for joint replacement and spinal fusion. Patients who go to India would have no out-of-pocket expenses or deductibles. Their travel, and travel for a companion, would be covered. I couldn't find out how much patients would save by going to India, but the self-insured employer would save between $30,000 - $50,000.

So why am I writing about this in a blog about ethics?

Here's why. Better governance of the U.S. health "system" requires better public understanding of the dynamics of the industry. Currently, public understanding is pitiably low. Employees tend to believe that their employers pay for health insurance, and don't understand that they're the ones who pay (through forgone compensation). Patients tend to believe that more care is always better care, and that what the physician recommends is ipso facto "medically necessary." Physicians tend to believe that Americans are incapable of accepting limits, and that they must therefore recommend any intervention with the slightest chance of providing benefit without considering costs. And woe unto anyone who doesn't automatically agree that "health is priceless."

Companies like Serigraph are - potentially - small communities. Workers know each other, and when labor-management relationships are good, there is opportunity for open deliberation about health care choices. Self-insured businesses can - potentially - take a truly business-like approach to health care, as by asking "what do we get for our money?" and "how do we get the biggest bang for the bucks we spend?" And large self-insured companies, even if widely dispersed geographically, can orchestrate electronic town meetings on important topics.

I can't think of any health policy mavens who recommend basing health insurance on employment status. But that's the system we have for the foreseeable future. Once five or ten self-insured employers demonstrate the potential for thoughtful deliberation about health care and can show bottom line impacts, like the Serigraph-Wellpoint medical tourism benefit, we'll see others emulating the practice. That process will contribute, at least a bit, to improved health policy literacy in the United States.


Anonymous said...

Jim, in your opinion, what are the top three ethical issues faced by insurance companies? What are they doing to handle these issues?

Jim Sabin said...

Dear anonymous -

Thanks for this big question!

I'd choose the ethical dimensions of (1) cost containment, (2) benefit design ("product design" in insurance lingo) and (3) managing care, as my hit parade of issues.

Alas, I don't have information on the internal workings of the largest national companies. Three not-for-profit plans - Group Health Cooperative, Harvard Pilgrim Health Care and Kaiser Permanente all have ethics programs that provide internal advice about values-related matters. National organizations like the American College of Healthcare Executives (ACHE) and America's Health Insurance Plans (AHIP), and state organizations like the Massachusetts Association of Health Plans sponsor ethics symposia that foster a certain amount of shared deliberation.

As I wrote in my October 20 posting, I believe that health plans, like hospitals, should have ethics committees/ethics programs. But that idea hasn't yet spread very far.



Mats said...

Dear Jim,

Do health insurance plans in USA presently cover expenses under Medical Tourism? If yes, which companies do so?

Also, what are legalities companies like WellPoint would face if they recognize Medical TOurism?