Should You Have Surgery Abroad?

En español l Vince Ellis needed a new knee. What the 58-year-old network administrator got, in addition to knee-replacement surgery at an internationally accredited hospital, was an all-expenses-paid trip to Costa Rica, a two-week stay in a four-star hotel, and daily visits from a nurse and physical therapist, all thanks to his employer, North Carolina–based HSM Solutions. What's more, he's now back at work, pain free, his retirement savings intact. "I didn't pay out of pocket for anything," he says.

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As companies and individuals look for ways to curb the escalating costs of medical care, stories like Ellis' are becoming more common. Roughly a million Americans are expected to go abroad for medical care this year, notes David G. Vequist IV, director of the Center for Medical Tourism Research in San Antonio — up from about 750,000 in 2013. Dental work tops the list of travel-abroad procedures, accounting for about a third of all health-related trips, followed by surgeries such as coronary-bypass and bariatric operations, at 29 percent. About 13 percent of American medical travelers seek cosmetic surgery, and 7 percent get orthopedic procedures such as hip and knee replacements.

Plus, employer-paid surgeries abroad appear to be taking hold: According to a 2014 survey by HR consulting firm Aon Hewitt, although only 5 percent of employers currently cover those surgeries, 25 percent say they may add this in the next three to five years. Ellis' employer, with 2,500 employees, has saved nearly $11 million on health care since the company started its medical-travel program in 2010, according to benefits director Tim Isenhower.

"The international medical marketplace is about to take off," says Marty Makary, M.D., a leading hospital quality and safety expert based at the Johns Hopkins University School of Medicine in Baltimore. "We're living in the era of the high deductible — $10,000 in the bronze family plan under the new health law. People are paying more and looking to cut costs."

If you're thinking about having surgery abroad — or curious about what it might entail — here's what you need to know to get the best outcomes.

Who pays?

Most Americans getting surgery abroad pay their own way — they're typically uninsured or underinsured or are seeking services not covered under most medical plans, such as cosmetic procedures or expensive dental restoration. But these days insurers and employers, both public and private, are not only picking up the cost for overseas care — some are even throwing in a cash bonus for the employee.

How much can I save?

A lot: See our medical tourism comparison chart.

What role does my local doctor play?

"Getting a first opinion locally is a good starting point," says Makary. Expect to have your physician at home make a diagnosis and evaluate your fitness for travel. Also be sure he or she is willing to share your records with medical professionals involved with your care abroad. After you return home, your local doctor should be prepared to coordinate any needed aftercare. But be prepared for pushback; American doctors are obviously competing for the same business.

How do I pick a doctor or facility?

Start with the website of the Joint Commission International (JCI) — the global arm of the Joint Commission, the major accrediting agency for U.S. hospitals — which requires hospitals to meet high standards for safety and quality. (See "Assessing the Risks" on the next page.) Those with JCI accreditation — more than 660 worldwide — are usually larger and have better resources.

Seek board-certified specialists who have successfully performed the procedure in question numerous times, and ask to talk with other American patients the physician has treated. Consider retaining a third-party medical-travel facilitator, who can make introductions, manage appointments and handle your travel plans. But beware: Some facilitators earn referral fees to get patients to certain hospitals. And facilitators should not be reading X-rays or giving medical advice, says Josef Woodman, CEO of Patients Beyond Borders, an online consumer resource for medical travel.

After deciding on a destination and doctor, get the details of your agreement in writing, including the treatment, supplies, care and any extra amenities covered.

What can I expect on the ground?

Ideally, the medical-travel facilitator or the hospital will arrange to receive your medical records and make sure home and foreign doctors are in agreement about the treatment. You will likely be picked up at the airport by an English-speaking concierge and taken to the hospital for tests or blood work and to meet with the surgeon. Some medical tourists spend the night in a hotel before being admitted to the hospital. In many cases someone will be by your side throughout your hospital stay.

After you're discharged, expect to stay in the hotel for a few days or more, depending on the surgery, receiving any appropriate post-surgery therapy on-site. If it's part of the package, you may be driven to some local attractions. (But don't sunbathe, swim or drink alcohol without a doctor's clearance, the Centers for Disease Control and Prevention [CDC] cautions.) When it's safe to travel, you'll be taken to the airport and your records will be sent to your doctor at home.

Should I take a companion?

If you can, yes. This provides peace of mind, and if something goes wrong, there is someone there who knows your preferences and your medical history. In fact, some of the new travel plans offered by insurers and companies actually pay for the travel and lodging of your spouse or other companion.

What's the follow-up procedure?

Follow-up depends on the surgery. But get directions on aftercare before you are discharged from the hospital, including any instructions for follow-up care at home. As soon as you arrive back, arrange to see your local doctor.

How do I get records to my physician in the U.S.?

If you are not dealing with a facilitator who handles this, ask for a copy of all your records, including X-rays and other images, to take back to the U.S., or ask that they be sent digitally from the foreign facility. Make sure they'll be available in a form your doctor at home can understand (such as in English).

What if there are complications?

Things can go wrong, even at respected American hospitals. Ask upfront if the price that was quoted includes care for any complications, such as a post-surgical infection, that might arise.

What if the doctor or hospital has been medically negligent?

News reports of deaths from surgery and botched cosmetic procedures abroad do arise; most recently, a series of surgery mishaps in the Dominican Republic warranted a warning from the State Department. But it's tough to sue a foreign hospital or physician, and even if you do win a lawsuit, it can take a long time — even decades — to recover any damages.

One solution is medical travel insurance. This covers medical malpractice and follow-up care with a death or disability benefit. The cost depends on the procedure, says Tracy H. Simons, president of Custom Assurance Placement, which offers such insurance. Typically, though, it is between $350 and $600 per trip.

Assessing the Risks

José Sánchez's gastric bypass surgery in 2008 should have been routine. But his stay at a hospital in Ciudad Juárez, Mexico, stretched to 10 harrowing days after he developed a leak at the surgical site and then a blood infection. Family members finally had the computer-software consultant from El Paso, Texas, transported by ambulance back to the U.S., where he had multiple surgeries to fix the botched procedure. Stories like Sánchez's are reason enough to keep some patients from crossing borders for medical treatment. But experts say you can get safe and effective care in all corners of the globe — and equally disastrous outcomes at home. To decrease your risk of unsafe care abroad, follow these steps, provided by Sharon Kleefield, former director of Harvard Medical International, an international medical-consulting arm of Harvard Medical School.

1. Opt for accreditation. The Joint Commission International is the best-known global accrediting body. But there are other reputable accrediting organizations recognized by the International Society for Quality in Health Care, a network of accrediting bodies around the world.

2. Ask about specific safety and quality data. Find out about infection rates, specifically catheter-associated infections, bloodstream infections and surgical-site infections (look for below 3 percent); the hand-hygiene program; the tracking of patient falls; and the use of prophylactic antibiotics.

3. Seek private hospitals tied to "brand-name" U.S. hospitals. Leading U.S. health systems such as the Cleveland Clinic, Johns Hopkins and the University of Pennsylvania have developed relationships with foreign hospitals that have some of the same safety standards as their U.S. counterparts.

4. Follow common sense, particularly regarding air travel. Long flights can magnify the risk for deep vein thrombosis. Plus, the CDC advises patients not to travel for 10 days after chest or abdominal surgery, because of airplane cabin pressure, and for seven to 10 days after cosmetic surgery.

— Beth Howard

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