Beauty from Afar

Chapter 2 Page 9 | Prices in the United States and Abroad

Consumers who consider going abroad to save money for cosmetic surgery, dental work, or any other kind of medical care, will hear these bromides, either from voices in their heads or from well-meaning friends and relatives:

• You get what you pay for.
• If it sounds too good to be true, it probably is.
• Quality doesn’t come cheap.

One does not have to have an intimate knowledge of international economics to understand why prices for high-quality cosmetic surgery can be far lower in less-developed countries than in the United States or Western Europe. A good surgeon is an artist, a psychologist, and modern-day wizard of sorts who transforms and restores; but he or she is also a businessperson. Cosmetic surgeons treat patients and are paid fees; cosmetic surgeons whose services are in demand can and do charge higher fees.

Simple, right? You get what you pay for, and quality doesn’t come cheap. However, among other things, geography matters a great deal. In your own town or city, you may find a range of prices from different cosmetic surgeons, as you might expect. Well-known surgeons with years of experience and hundreds or even thousands of satisfied customers will charge the most. A surgeon fresh from his or her residency, just starting out, trained but relatively inexperienced, will charge less. It is not unheard of for surgeons just starting out to offer reduced fees to clients who will agree to provide testimonials or referrals or otherwise participate in marketing the new business.

In your town, there will also be doctors and surgeons who may not be board certified in plastic surgery who nonetheless legally practice it, to an extent. The ASPS warns that such practitioners may be less-safe choices and, generally speaking, one would guess that they are right. Still, it goes on.

The average price of a typical facelift in the United States performed by a board-certified plastic surgeon in an accredited surgical facility, including surgeon’s fee, anesthesia fee, and operating facility fee, is in the $7,000 to $9,000 range, according to InfoPlasticSurgery.com (2005)

That might be the range in your town. But if you live in New York City, the range might be 50 percent higher. If you live in parts of the less-urban South or Midwest, the range might be a little lower. Geography matters, even within the United States. There is more demand for cosmetic and aesthetic surgery and procedures in urban areas and on the coasts; and the costs of living and of doing business are correspondingly higher. So how can board-certified, experienced surgeons working in modern facilities in Mexico, Brazil, Costa Rica, the Dominican Republic, Thailand, India, and other countries charge so much less? While a facelift abroad is more likely to cost between $3,500 and $6,000, including travel, meals, and accommodations, the costs of living and of doing business is correspondingly less in these countries. The top surgeons in the world, those with international reputations, can charge and get U.S. prices wherever they may be, but the many trained and qualified surgeons who aspire to be known as among the elite in the world must charge far less to draw patients from abroad, including the United States. And they can make a good living doing so.

Many think U.S. surgeons are greedy, but I do not think that is the case. They face significantly higher costs than do their counterparts and peers in other countries. In many ways, the reasons prices for cosmetic and other surgeries are lower in other countries than in the United States and western Europe are the same reasons why it is less expensive to produce DVD players or textiles abroad: They have less-expensive land, less-expensive construction costs, lower labor costs, lower taxes, and lower administrative costs. It is a mistake to single out any one thing as being responsible for the difference.

Malpractice insurance costs are also partly to blame. Though malpractice rates vary, depending on amounts of coverage, U.S. surgeons I interviewed said they each pay between $40,000 and $70,000 annually, compared to the less than $6,000 a year a Brazilian surgeon I know pays. This is a substantial difference, yet a small part of the overall equation. About the only business expense that is the same for surgeons regardless of where they live is medical equipment and medical supplies.

Price is relative from country to country, and a patient looking at the possibility of traveling abroad for care can responsibly factor that in. Some prices are so low that one can not help but be suspicious. Substantial inquiries are merited and references should be required. Cosmetic and elective surgery prices in the Far East are, for the most part, somewhat lower than those in South America, which are somewhat lower than those in Central America. I know that there are good surgeons in all those places.

Surgeons in the Far East, in fact, may be more likely to have trained in the United States and be fluent in English, though they have no monopoly on either of those things.

The cosmetic surgeon who charges the highest prices in your town may well be among the best and will almost certainly be among the most experienced. But paying the highest price does not guarantee the best outcome. Is a $10,000 face-lift in New York City better than a $7,000 one in Cincinnati? Is either better than a $3,000 one in Brazil? It depends.

I have talked to people who are unhappy with their expensive cosmetic work and people who are thrilled with the quality of their inexpensive results. For every anecdote, there is another one to give lie to the first. Beyond the borders of the United States, options abound for those willing to take the time to investigate, analyze, and choose.

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Chapter 1 Page 8 | Tip of the Iceberg — and a Trend

Global competition for health-care dollars is relatively new. The balance is shifting. From the perspective of many health-care professionals in the United States, Canada, and the nations of western European, this is unsettling. It highlights some of the deficiencies in western medical systems: In the United States, high costs and a high number of uninsured; and in Canada and western Europe, long waits and similarly high costs for elective procedures. At one time, only a small number of people from the developed nations went abroad for inexpensive plastic surgery, while a large number of wealthy people from countries with lesser medical care came to the West for advanced care, treatment, and surgery. The estimated 100,000 people (and growing) who now leave the United States annually for plastic surgery only represents the tip of an iceberg for medical tourism as big business.

There are already large success stories that have legitimized this point of view. Bumrungrad International Hospital in Bangkok, Thailand, is the best known; in 2004 it boasted treating more than 350,000 patients from 150 countries. India is hurrying in the same direction, projecting that medical tourism could be a $2.2 billion business by 2012. Put this way, it sounds huge and economically threatening to the United States and its medical-care system. One can imagine that 10 years from now, the lion’s share of the U.S. cosmetic and other elective surgery businesses will be offshore; that U.S. insurers and Health Maintenance Organizations (HMOs) will be putting a hefty percentage of nonemergency-care patients with expensive treatment or surgical needs on airplanes out of the country rather than sending them to local doctors, hospitals, and surgeons. This is a highly exaggerated scenario.

Medical tourism, as such, does not represent a substantial immediate threat to the medical system of the United States, or any other country for that matter. What, after all, is a few billion dollars compared to the $1.7 trillion spent on health care in the United States each year? The billions represent a small shift in revenues in a worldwide multi-trillion dollar health-care system. By serving the uninsured and the underinsured in the United States and by providing an alternative to long waits for treatment or surgery in Canada and western Europe, medical tourism in a sense is augmenting the health-care systems of developed countries, filling and bridging gaps, providing another safety net.

As for aesthetic and cosmetic surgery — the “tip of the iceberg” for the medical tourism phenomenon — overseas surgeons are filling a need. Time and time again, I have heard from surgeons in Mexico, Brazil, Costa Rica, and the Dominican Republic: We are not taking patients away from U.S. plastic surgeons. Our patients come to us because they cannot afford U.S. prices. If not for us, they would not have surgery at all.

There are many doctors and surgeons in the United States who would prefer that medical tourism just go away. And cosmetic surgeons, personally and through their membership organizations, have thus far expressed most of the public concern and opposition. This is understandable, but there are degrees of opposition, and one would be mistaken to think that all are of the same mind. It is reasonable to suspect that, as time goes on, more medical professionals in the United States will take a less U.S.-centric position and, generally accept that they have an international community of peers.

Just a few months after I returned from my dentistry adventure in Costa Rica, I had an appointment with my ophthalmologist. I am extremely nearsighted and have been from an early age. I’ve worn contact lenses for 36 years, which seems an impossibly long time. In the last several years, my eyes changed such that I was perilously close to requiring bifocals or, as an alternative, reading glasses to wear with my contact lenses. My eye doctor, on this visit, told me that I was an excellent candidate for Lasik eye surgery. I knew what Lasik was, certainly. I knew a lot about it. What lifelong myopic didn’t read up on that when it came out? But I had never before been told I was a good candidate for it.

“It’s improved a great deal in the last two years,” she told me, in response to my questioning about the procedure’s reliability and success rate. “They’ve refined it. We probably won’t see it get much better than it is right now, not anytime soon.”

I knew that Lasik surgery costs more if one is severely nearsighted. She nodded when I guessed the cost. “Yes, you’d probably be paying around $4,000.”

I hesitated, and then told her my Costa Rica story, the short version. And I asked, point blank if she would help and support me if I chose to get Lasik surgery done overseas? Would she work with the foreign doctor, help me get the best care I could? Because I didn’t have $4,000 for Lasik surgery.

She looked me right in the eye.

“Absolutely,” she responded, firmly, surprising me a little. And we had a long talk about where would be the best place to go. My ophthalmologist had a slight preference for India, though we agreed, laughing, that as a second-generation Indian, she perhaps has a prejudice.

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In Chapter 1 of Beauty from Afar, I suggested that medical tourism was already a big business in 2005 and that it might be acting as a safety valve for the U.S. health-care system. I was right on both counts.

Chapter 1 Page 4 | Patients Going Abroad: A Burgeoning Industry

Medical tourism was and is a big business and that fact has been a source of great frustration to entrepreneurs who believed then, and even today, that therefore it can be tamed, routinized and turned into a corporate profit engine.  The biggest problem with that has been that the part of medical tourism that looks like it would be very profitable — putting Americans on airplanes and sending them overseas for surgery — is not a very big part of the medical tourism business at all. It is a very small part of the picture, relatively speaking, and will remain so unless and until American businesses and government embrace medical tourism.

Most of medical tourism from the United States is still for elective procedures, dentistry and cosmetic surgery; and the Great Recession has affected that business substantially. Yes, people are more interested than ever in saving money. However, through the medical tourism boom of 1998-2007 or so — a lot of Americans were paying for their cosmetic surgery and dentistry with credit cards or by taking second mortgages out on their homes. That is not happening quite so much any more, for obvious reasons.

Yet medical tourism is working well as a safety valve for many people the world over who cannot get or afford the care they need or want locally. It has been consumer driven. It is in the hands of patients.

Big research companies talk about medical tourism being worth many billions of dollars, with many more to come. They are right, though their methodology is often deeply flawed and even laughable. But those medical tourism dollars are spread out all over the world and are very difficult to count.

The next segment will talk about spiraling medical costs in the U.S. There’s a topic that certainly hasn’t gone stale in a few years. I’ll be interested in whatever it was that I had to say. 😉

Chapter 1 Page 4 | Patients Going Abroad: A Burgeoning Industry

The story of modern medical tourism is, at one level, also part of the story of the changing global economy, of giant and accelerating shifts in the production of goods and services to nations that have lower costs than the United States and Western Europe. The catch-all phrase for this is  “globalization,”  and it represents, depending on whom one listens to, anything from the end of civilization as we know it to the last, best hope of mankind. The truth, as always, is more complicated, though that is of little solace to workers in the United States whose jobs have been outsourced, whose factories have been off-shored, who are still trying to figure out just exactly how  “free trade”  is helping them.

For the estimated 42 million people (1) in the United States who lack adequate medical insurance, however,  the globalization of quality medical care and services actually is one of the benefits of free trade. And the availability overseas of comparatively inexpensive elective procedures, including plastic and cosmetic surgery,  gives
Americans who are willing to travel outside the country options to which they are turning in increasing numbers.

Medical care, however, is not like manufacturing textiles or CDs or writing computer programs or providing technical support via telephone.  In the United States, and everywhere else, the first requirement of a medical-care system is that care be available locally, and the second is that it is available swiftly in an emergency. No one is going to go abroad for a simple check-up, for a flu shot, to have a cavity filled, to set a broken bone  —  not unless they live near a border and it is convenient to do so.  Increasing numbers of Americans willing to travel overseas for certain kinds of treatments and surgeries will not have a radical impact on the general delivery of health-care services in the United States anytime soon. In some areas, the effect is ambiguous; medical tourism is a back-up system, a safety valve for the American health-care system.

That an uninsured North Carolina man would have heart valve surgery in a state-of-the-art hospital in India with top-flight surgeons and eight registered nurses tending to his needs for $10,000 instead of in a hospital near his home for $200,000, as reported by CNN in January 2005,   does not deprive the hospital in the United States of $200,000 in revenue. The man didn’t have insurance and he didn’t have the money. Having surgery in India was a way to save or extend his life in a way that he could afford. His only choice in the United States was to wait until he had a heart attack so that he could be treated on an emergency basis. Assuming he survived, sticky financial negotiations that might have led to his bankruptcy would be left until later.

Medical tourism, in the short run,  provides a similar safety valve for the public health-care systems of Canada and Western Europe where the problem is not so much cost as it is accessibility. People needing or wanting non-emergency medical treatment can wait months to see a doctor. Canadians may even venture to the United States for care, despite the cost, to avoid average waits that were as high as 17.9 weeks in 2004. (2)

In June 2005, the Deccan Herald News Service of India reported that the largest holiday tour operator in Great Britain, Thomas Cook,  and the Apollo Group of India were in advanced negotiations over all-inclusive medical tourism packages. Those close to the deal speculated that the number of Britons who might travel to India for health care could rise from 400 or so annually into the tens of thousands,  should the trip become sufficiently routine.

(1) National Center for Health Statistics, 2004 National Health Interview Survey. Early Release of Selected Estimates. (Author’s Note, 2009: This has been a much-debated number for some years. But most sane people agree that the number of uninsured and underinsured people in the United States is “a lot.”)

(2) Fraser Institute (Vancouver, B.C.) 14th annual edition of  “Waiting Your Turn: Hospital Waiting Lists in Canada” (2004).

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Introduction Page 5 | Seeking Beauty from Afar: How I Got My Smile Back

Competition for the United States

The new context emerged out of the Far East and spread from government officials and hospitals to business journals. In India, Thailand, Malaysia, and other countries, medical tourism was not a fad; it was a business sector, an important part of the new Asian economy. Sure they were doing inexpensive boob jobs, and if that was all it was, maybe the story wouldn’t have changed.

But they were also doing inexpensive open-heart surgery and opening brand-new hospitals that rivaled any in the United States. The story grew in 2004 and spilled out over the Internet. In 2005, it splashed across the front pages and onto cable and network news in the United States. Two premises about traveling abroad for surgery now co-exist, uneasily. The first is that traveling abroad for surgery or medical care is unacceptably risky and should be avoided. This is certainly the general view of the medical profession in the United States, and it is shared by the bulk of the population. If one subscribes to this premise, the idea of traveling abroad to save money on elective procedures such as plastic or cosmetic surgery sounds especially foolhardy, as in, “Who cares if it’s cheap? You don?t even need it!” or “Why not save up until you can afford to do it right?”

The second premise is that the rest of the world, or at least some of it, has caught up with the United States in quality of medical care and facilities, and that going abroad for lower costs can be the best option, especially for high-cost elective and uninsured procedures and surgeries. Under this view, going abroad for plastic and cosmetic surgery is not a last, desperate resort but a best affordable option for the hundreds of thousands, even millions of people who desire such procedures annually. If the doctors and facilities overseas are up to U.S. standards but the prices are 30 to 80 percent less (even factoring in travel expenses), what is so hard about that decision?

There is truth in both premises, of course; and I considered that I was unprepared to write Beauty from Afar until I could argue impressively for either. One thing — perhaps the one thing — that supporters of either view would agree on is that consumers of medical services should do their homework and be as informed as humanly possible about their options. To that end, I offer Beauty from Afar, representing, as it does, about 18 months of day-in, day-out homework and research into traveling abroad for medical care, particularly plastic and cosmetic surgery, and dentistry. This book is intended as an introduction to medical tourism and as a guide to those who might want to consider traveling abroad for health care, whether as a best affordable option or as a last resort.

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