Beauty from Afar

Chapter 3 Page 5 | The Media Imprimatur

The media in the United States did not really discover medical tourism until 2004-05, and it was found in the Far East rather than in central and South America. It was Bumrungrad Hospital in Thailand and the Apollo Hospital Group in India and Penang Adventist Hospital in Malaysia that made 60 Minutes and the front pages of the Wall Street Journal and The New York Times, not the plucky surgeons and dentists of Costa Rica, Mexico, and Brazil — even though far more U.S. citizens were heading South for inexpensive medical and dental care and surgery than were heading to the Far East. There are a few good reasons for that, which I offer not as an apology for the media but as explanation:

1. The story wasn’t about cosmetic surgery, which, despite its popularity and the professionalism of its practitioners, doesn’t get the same treatment in the news as does “real” medicine. Cosmetic surgery news is fluffier, more frivolous, than open-heart surgery news. The international hospitals of the Far East, wisely, didn’t play up cosmetic surgery — though they do a lot of it. They played up cardiothoracic surgery, and their state-of-the-art technology and facilities, and thus were taken more seriously. For the first time, much was made of the fact that there is an estimated 42 million people in the United States who lack adequate medical insurance who could go out of the country to get treatment they could not otherwise afford.

2. The story was delivered in part as a business story with big dollar signs, the kind that gets attention from the media. India put a $2 billion sticker on medical tourism. As previously noted, Bumrungrad sees more than 350,000 patients a year.

3. The story was generated by big multipurpose hospitals, and supported by the tourism and economic development officials of their respective countries. This is the way countries in the Far East go after markets, and there is nothing in Central or South America to compare as yet.

As we move through the first decade of the 21st century, medical tourism is still both newly discovered and in transition. The tip of the iceberg remains elective medical care, mostly cosmetic surgery and dentistry; beneath the surface is the larger consumer health-care market of North America and Europe.

And the media is paying attention. In February 2006 a West Virginia state legislator introduced the first bill in the country providing for the outsourcing of medical care to foreign countries. In Chicago, Blue Cross/Blue Shield investigated and then approved payment for an insured child’s heart surgery in India. And when President Bush visited India for the first time in March 2006, the two countries released a statement pledging American support for Indian efforts to support medical tourism, saying there is “enormous potential for collaboration” in health tourism.

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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 7 | 100,000 Fellow Travelers — or More

(Author’s Note: The reader should be aware that the following numbers were calculated for 2004-2005. I do not claim they are representative for any other time. If I had to guess right now, in 2009, a time of global recession, I’d say that cosmetic surgery abroad might well be in the doldrums, just as it is within individual countries such as the United States.)

Today, with access to the Internet, the millions of prospective and actual cosmetic surgery patients in the United States can be remarkably well-informed before ever setting foot in a surgeon’s office. They are familiar with the procedures;  they’ve seen before-and-after pictures. The Internet and television have supplemented traditional word-of-mouth marketing of cosmetic surgery, and many U.S. doctors build their practices substantially through their Web sites.

But the Internet also opened up this vast U.S. market to aesthetic and cosmetic surgeons abroad.  And in increasing numbers, they are going after the U.S. market directly.

How many people from the United States are actually going south of the border (or anywhere else) to save money on liposuction, face-lifts, tummy tucks and the like? In recent news stories, the conventional line, almost to the point of cliche, was  “no one knows.” I have been told by several U.S. surgeons who cared to speculate that the numbers are negligible;  however, these have been the same surgeons who are most concerned about (or opposed to) people going overseas for surgery. Some doctors and journalists have guessed it to be in the  “low thousands”.

This is almost certainly bad guesswork, though it all depends on who and how one wishes to count.  Consider, and do the arithmetic along with me: Costa Rica, the “Beverly Hills of Central America,”  where there are perhaps 35 to 40 cosmetic surgeons who work primarily on patients from the United States. The best and most experienced are busy constantly, and some will do several surgeries a day. These board-certified surgeons each handle as many as 40 to 50 U.S. patients a month.  Even accounting for slackers, one cannot put the annual total at less than 5,000. It could be double that or more.  A prominent surgeon I know puts the total at more than 20,000.

One can speculate conservatively that a similar number of people visit Costa Rica for just dental work, as I did. There are a lot more dentists,  according to one surgeon, and there is some overlap, as many patients will have both plastic surgery and dental work done on the same trip. Many procedures are also done by non- board- certified physicians and surgeons.

Brazil,  a mecca for cosmetic and plastic surgery with a reputation that precedes and, in much of the world, overshadows that of Beverly Hills:  There are more than a million Brazilian-Americans in the United States. The population has tripled since 1990.  Perhaps there was a time when only hundreds or a few thousand U.S. residents traveled to Brazil for cosmetic surgery annually, but that time is past. Brazilian surgeons are polishing their English and their Web sites and building new facilities. Count another 10,000 and growing.

Mexico, the most telling of all: There, more than 900 board-certified plastic and cosmetic surgeons ply their trade. Despite a stream of cautionary and negative news reports about the practice through the years, undoubtedly far more U.S. residents visit Mexico for cosmetic and plastic surgery than any other country. There are more than 30 million Mexican-Americans in the United States, as a receptive base market. Mexican surgeons advertise in the United States and even visit our country regularly on marketing expeditions, mostly in the South and West. It is not reasonable to guess that “a few thousand” U.S. residents head for the border annually for cosmetic surgery. I venture an educated estimate that the number is at least 40,000.

Tourists seeking liposuction or face-lifts do not declare their intentions at the border, and I have run across only a few doctors and surgeons abroad who can give a good estimate of the number of U.S. patients they see themselves, let alone an aggregate number for their country.  But the number for Mexico adds up quickly. I’m told that perhaps half the doctors do little or no work on patients from the United States.  Still, if the other half averages two U.S. patients per week, the total would come to nearly 50,000. This does not account for cosmetic dental work or the number of patients who get cosmetic surgery from non-board-certified physicians.  It also ignores the fact that there are hundreds of thousands of U.S. citizens living in Mexico, perhaps as many as a million, who presumably are likely to seek medical care, including cosmetic surgery, from local doctors and surgeons.

The Dominican Republic, another medical tourism destination that has been vilified, more often than not, in the popular media in the United States:  There are approximately 60 busy cosmetic surgeons in and around the capitol, Santo Domingo. For many of them, more than half of their patients come from abroad, mostly from the United States. Moreover, there are more than a million Dominicans residing in the United States, at least 600,000 of them in the New York City metropolitan area alone.

Dominican surgeons travel to New York regularly to make presentations to prospective patients.  The prices of even the best, most-qualified surgeons in the Dominican Republic for common surgical procedures are 50 to 70 percent less than what is charged in the United States. Business is booming. It is not unreasonable to guess that board-certified plastic surgeons in the Dominican Republic, plus other doctors and surgeons who perform cosmetic procedures,  see at least 10,000 patients a year from the United States, not including dental patients.

The rest of the world: A “few thousand”  more from the United States travel to other Central and South American countries, all of which are represented in the United States by growing immigrant groups. Destinations in the Far East are growing in popularity;  Eastern Europe and South Africa are more popular with western Europeans as places to go than they are with Americans, but surgeons in those countries have only just begun competing for the huge North American market.  And Malaysia and Thailand are both increasingly popular destinations. Add another 10,000 to 20,000 to the total, easily.

I am comfortable, then, in conservatively guesstimating the number of U.S. citizens currently traveling abroad for plastic and cosmetic surgery at something in the high five figures, approaching 100,000. This would be about 5 percent of the 1.7 million estimated cosmetic surgeries performed in the United States.

I don’t have a similar feel for the total number of U.S. patients who go abroad for dental care, other than to suspect that it is similarly substantial. Certainly, at least a dozen major dental practices in Costa Rica thrive on serving the U.S. market.

An assertion that the number of U.S. residents, mostly women, who would travel abroad for cosmetic surgery might be rapidly approaching 100,000 annually, or even higher, will no doubt nettle some doctors and surgeons in the United States. Yet how are we to get a grip on the phenomenon (or “problem,”  if that is your point of view) if we do not attempt to get a handle on its size?  Until the last decade, the story of what is now called medical tourism was mostly about people in other countries coming to the United States for sophisticated medical treatment, if they could afford it. And the traffic has by no means completely reversed.  Many thousands of people still come to the United States for health care, including cosmetic surgery. Almost certainly, far more money comes into the United States from abroad to pay for medical care than leaves the country.

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