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 6 | Dear Dr. Rubinstein …

When I contemplated traveling abroad for dental work, it took me a month of research on the Internet before I was finally ready to make a direct inquiry. A month — and that was just to feel confident about choosing a country from which I would select a dentist! I picked Costa Rica over Thailand because proximity to the United States played a big role in my thinking. “I don’t want to go too far if I don’t have to.” This, from someone who had thought nothing of taking off for Africa for a year, at age 20. (Which is a whole ‘nuther story.)

There was a wealth of information available on dentists and dentistry in Costa Rica at the time, more so than anyplace else (except for the United States, of course).  I wrote to the aforementioned Telma Rubinstein, D.D.S., of Prisma Dental in San Jose, Costa Rica, on February 16, 2004.  Prisma had a Web site.  I confess I chose them as first contact because they had a female dentist. I felt sure I would have a lot of questions,  and my instinct was that a woman would be more likely to be patient with me.

Dear Dr. Rubinstein,

I am writing to inquire about having cosmetic dental work done at your practice in Costa Rica.

My dentist here in Connecticut, two years ago, had taken a mold of my bite and recommended, as I recall, eight or 12 porcelain crowns. I must say I concur with his opinion. My teeth are quite worn and small, at 47 years of age. I also have a badly chipped front tooth. I could send you digital photographs, if you’d prefer to see that way.

My dental insurance at the time would not cover any of the considerable fee, however. I now find myself without dental insurance at all, but I recently heard that practices such as yours could do a fine job on the work I require at a significant savings. What can you tell me beyond what I have read on the Internet? How would we proceed?

Thank you for your time,

Jeff Schult

I never had to write to another dentist in Costa Rica or elsewhere. During the next 6 weeks, I peppered Telma, as she asked me to call her, with more than 20 e-mails filled with questions about her credentials and experience,  my teeth, prices, travel and accommodations, and Costa Rica in general, and she patiently answered every one.

Still, I didn’t really make up my mind until after I asked her if she had any problems with my writing a magazine article about my experience.  She had no qualms at all, and I took that as a sign of her complete confidence in her ability. I realized that I already knew more about Telma Rubinstein than I had ever bothered finding out about any doctor or dentist who had treated me in the United States.  Later, I felt kind of bad about having been so difficult.  “I put you through the wringer,”  I told her when we finally met. She laughed. I had been easy, she said, compared to many of her other prospective patients from the United States: “Some of them, Jeff, they ask me so many questions that I feel I have been stripped naked!” Since then, I have heard similar stories from doctors, dentists, and surgeons around the world who treat patients from the United States.

As I’ve already stated,  I believe that the United States has the highest quality of medical care in the world, the most and the best medical facilities, the highest level of technology, and the most stringent regulations and standards. Does that mean that all doctors and dentists and surgeons in the United States are better than all of their peers abroad, or even that most of them are?  I do not think even the most xenophobic member of the American Medical Association (AMA) would dare make such an assertion in intelligent company.  Even the most vociferous critics of medical tourism acknowledge that there are many fine doctors, surgeons, and dentists around the world working in facilities that are as modern as anything in the United States.

But the official party line of the medical establishment in the United States is:  Traveling abroad for surgery is generally far more risky than having surgery in the United States. Bad things are far more likely to happen. You shouldn’t do it.

The recent history of medical tourism in the United States suggests that more and more prospective patients for elective surgery, particularly candidates for cosmetic and plastic surgery, are rejecting the medical establishment’s No. 1 considered wisdom in this matter.  By far, the No. 1 reason they are doing so is cost. Aesthetic and cosmetic surgeries are elective services, paid for out-of-pocket by patients. Wealthy patients are not so price-sensitive, but procedures are no longer for just the well-to-do.

The demand for aesthetic and plastic surgery has skyrocketed in the United States and around the world.  U.S. surgeons performed three times more face-lifts in 2004 than in 1992;  nearly eight times as many people had liposuction. (5) A whole new business in so-called minimally invasive procedures (like Botox and injectible fillers) was born in the space of a few years. In 2004, U.S. cosmetic plastic surgeons performed more than 9.2 million separate procedures.  The most visible sign of the broad acceptance of aesthetic and cosmetic surgery in mainstream society was the emergence of several popular (and controversial) reality television shows such as Dr. 90210, The Swan, and Extreme Makeover. The Swan and Extreme Makeover were short-lived, but that they made it to television at all was a sure sign that plastic surgery is no longer seen as just for the affluent.  Americans of more modest means also want to look good — but price matters.

(5) American Society of Plastic Surgeons Statistics. at www.plasticsurgery.org.

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Chapter 1 Page 2

Fast forward to April 2005, a year later. My phone rings in Connecticut, a little too early. “Did you see 60 Minutes last night?” the voice asks. I hadn’t, actually; instead, I had been sitting in a gymnasium in West Haven listening to my son play clarinet with his high school concert band. But I had known what 60 Minutes was doing. Weeks before, Ruben Toral, who is responsible for public relations at Bumrungrad Hospital in Thailand, had told me that CBS had been filming there.

Later, I watch a tape of the show and am frankly astonished that it portrays medical care in Thailand and India as being of the highest quality, and at a fraction of the cost of the same care in the United States. The lid is off, I think. It is not a new story to me, of course; but that 60 Minutes had done it raised the credibility level. If there was something awful about medical tourism, anything especially dangerous about going overseas for health care, surely they would have found it?

Millions of people saw the show. Hundreds of thousands of people — at least the ones who have already been overseas for health care — felt vindicated, a little less crazy. The next morning, I read, on a prominent mailing list on the Internet, this comment:

“This could turn out to be one of the most important stories 60 Minutes has ever produced. First, because it addresses one of the most critical issues in America: rising health-care cost (combined with the uninsured), and second, because the show’s audience are the prime consumers of these services: the aging baby-boomers. While I can see that it might take a few years for flying to Asia for major surgery to catch on, I predict that insurance companies will eventually find a way to use these options to force U.S. health-care providers to lower their prices. (Of course, then the battles in Congress will start …)”

Whatever sense I had of being privy to a secret vanished.

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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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Introduction Page 3 | Seeking Beauty from Afar: How I Got My Smile Back

A Nose Job in Iran?

I first focused on the bigger picture, which was plastic and cosmetic surgery in Costa Rica and elsewhere, and soon found myself swimming in a sea of Internet message boards. Mexico — was it safe? Had anyone been to Malaysia? Did South Africa make any sense at all? Why Spain for weight-loss surgery? Nose jobs in Iran, tummy tucks in Colombia, sexual reassignments in Thailand, new boobs in Brazil … it seemed that in every corner of the globe, plastic surgery was being performed for fees dramatically less than those charged by doctors in the United States and Europe, and it was even being done in places prospective patients could consider going to for a vacation.

Still, it was something one had to know about to find. It was a phenomenon, perhaps even a trend, but small — in fact tiny — when measured against the number of people who don’t leave the country to want cosmetic surgery. It didn’t even really have a name yet, though the mainstream media made periodic attempts to label it. “Lipotourism” was tried on for size (notably by The New York Times), but it didn’t really stick, describing, as it did, mostly a quick trip for fat suctioning and not much else. I’d run across “medical tourism” and used it once in an article, but it wasn’t in common usage. “Health tourism” was another borderline misnomer. As time passed, the term “medical tourism,” as uncomfortable as it is to some people, caught on.

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Introduction Page 1 | Seeking Beauty from Afar: How I Got My Smile Back

Stumbling upon an open secret

I became a “medical tourist” in the early spring of 2004, when I traveled to Costa Rica for major dental work I could not afford in the United States. I use the term medical tourism, with the benefit of hindsight, as a catch phrase for the unusual business of traveling a long way for health care. It did not gain currency in the media until later the same year. At the time, I considered myself … as what? Not a tourist. More of an exile, perhaps. Though there are certainly terrific dentists in
the United States, I couldn’t afford them. I was on the outside of the health-care system looking in.

My teeth and gums had deteriorated prematurely in my forties to the point where smiling was no longer an instrument of charm. I needed what dentists call full-mouth reconstruction. Insurance companies generally call it unnecessary and would rather wait a few years before contributing to the cost of what by then would be an entirely necessary full set of dentures. In any case, there was not an insurance plan in the world that would cover the $18,000 to $30,000 that a United States dentist would have charged for my full-mouth reconstruction — not unless I’d lost my teeth in a horrible accident, as opposed to simply having them wear away over time. I know. I shopped around.

All this I knew in 2001. By 2004, I had mostly resigned myself to having bad teeth. A quirky grin had become my all-purpose expression of approval. If my misshapen teeth appeared in a photograph, I touched them up with a bit of virtual dentistry. I hoped that what was left of my teeth would last me, functionally, until I was eligible for Medicare. I admit that the molars were still fine for chewing, that the ragged fronts could still tear food. “Let vanity go, you’re 48 years old,” said a voice in my head. I avoided looking at my teeth even when brushing them and tried not to be bitter.

On the evening of February 16, 2004, I was reading the latest messages on the Interesting People (IP) e-mailing list, an influential Internet forum hosted by Professor David Farber, often called, without much exaggeration, the Father of the Internet. The topic was the outsourcing of technology jobs overseas. Jim Warren, a computer professional and long-time online activist, went off on a mild tangent about how it is not just technology jobs that are leaving the country:

“… Many Americans fly to Bangkok to get needed (or simply desired) medical and dental procedures … everything from crucial transplants and sex reassignments to cosmetic surgery and liposuction. The surgery, hospital, and drug costs are almost nothing by comparison to U.S. medical, surgical, and hospital charges.”

Warren told of a good friend who had a laparoscopic adrenalectomy — an operation to remove a benign tumor of the adrenal gland — that would have cost $30,000 or more in the United States. In Thailand, she paid 100,000 baht — a little less than $2,600. The quality of care, he said, was outstanding.

Immediately, I was thinking about my teeth again. It had never occurred to me to shop outside of the United States for dental care. Thailand! It sounded a little crazy.

Nevertheless, 3 months later, after a lot of reading, correspondence, and consideration, I was reclining in a dental chair; not in Thailand but in San Jose, Costa Rica. The cost of my full-mouth reconstruction fit inside my credit card limit.  Six root canals, 14 crowns, and 10 days later, I was heading for home with perfect teeth and a dazzling smile for less than half of what it would have cost me at home.

I chronicled my journey for Northeast, the Sunday news magazine of Connecticut’s Hartford Courant. The article over time provoked more gratitude than anything I had written in 20 years of journalism. It also got a chilly reception from dentists in Connecticut. “Hey, maybe the Courant could get a cheaper reporter from Botswana,” was one of the more memorable gibes.

“You were very brave,” a friend told me. She meant, “I wouldn’t have done it. You always were a little crazy.” But I knew that I wasn’t crazy, and I also knew I wasn’t alone. While in Costa Rica, I’d met dozens of people who were in the country for health care — mostly cosmetic surgery and dentistry — and learned that San Jose had, for years, cultivated a reputation as the “Beverly Hills of Central America.” It was an open secret, decades old, spread first solely by word of mouth and later via the Internet.

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I added Curtis J. Schroeder’s Afterword for Beauty from Afar today, along with fussing with links on the table of contents page and updating the “About” page to reflect the fact that I am available for work and that I am open to the partnership and advertising possibilities inherent in this site.

Curt, as far as I know, is still group CEO at Bumrungrad International in Bangkok, Thailand; and I am still grateful for his kind words, written in 2006.

Yes, putting up the Afterword now is out of order. I thought about putting it up last. But I decided that anything that was really about the book and gives people the reasons why they might want to read it, ought to go up before I started posting actual chapters.

Besides, I love the Afterword and it makes me feel good to read it again.

So … next, I’ll put the jacket copy up, somehow; and then the Introduction … and then, I’ll probably start letting people know about the site and, little by little, post the 12 chapters. I’ll make pretty ebooks, in various formats, once I have pulled all the text out of the Quark file and massaged it sufficiently.

(January 2006)

A Bangladeshi, a Brit, an Arab and a New Yorker were sitting in a doctor’s waiting room …

What could be a preamble for an off-color joke is in reality the tangible face of the medical-tourism phenomenon. What brings together such a rich melange of people to a medical facility thousands of miles from the comfort of their homes? In fact, their motivation is as diverse as their cultures, languages, and geography.

The Bangladeshi seeks an alternative to the less-developed medical system in his own country. He comes for quality.

The British woman undergoing radiation therapy for her breast cancer is side-stepping the long queue in England?s socialized health-care scheme. She comes for access.

The affluent Emirati from the United Arab Emirates is seeing four doctors in one morning with a personal interpreter/valet in tow and a steaming cup of Starbuck’s coffee in his hand. He comes for service.

Then there is the New Yorker. What on Earth is he doing here? What has possessed this 55-ear-old upper-middle-class stockbroker from one of the most cosmopolitan cities in the world to leave behind arguably the most sophisticated medical system on the planet to have surgery in Asia? He is one of 40 million uninsured Americans who is self-employed, not rich, not poor, old enough to need his prostate removed but not old enough to qualify for Medicare. And he does not want to pay the high price for private medical insurance. He comes for price.

But the Americans can not be sold on price alone. Our friend from New York is a case in point. Of course, the price was 80 percent less than that of the U.S. quotes he got. But being a day-trader, he knows his research. He knows what he wants — a cutting-edge minimally invasive laser procedure for prostate removal by a surgeon who has done the most of that procedure in the world, in a hospital that is of international standard that could take him right away. His search brought him to Asia.

He came for quality?; and access?; and service; ?and price.

As an American who has lived in Asia for over a decade, I can safely say that we Americans are a demanding bunch. And it is truly a leap of faith to trust your health to a doctor that you have never met at a hospital you have never seen in a country you have to find first on a map.

This is the value then of Jeff Schult’s excellent guide to the world of medical tourism. Jeff has scoured the hot-spots of medical tourism, talked to the patients, Googled the Internet to within an inch of its life, and taken the plunge himself into overseas health care. The result is a balanced, unbiased, and thoughtful guide for the informed consumer. Beauty from Afar is an entertaining and practical handbook that includes important considerations that any prospective medical tourist would? and should? consider before making the “leap”.

I thought I knew a lot about the subject, having lived it for 10 years. Jeff has opened a whole new world of possibilities, and he has made me a student again. I am convinced more than ever that medical tourism is not a fad. It is not about “cheap” health care. It is about smart, well informed people looking for quality service at a reasonable price in a world where distances and lines drawn on a map are not the barriers they once were.

Decisions about your health are important. Read this book. Do your own research. Make smart, informed decisions. Maybe you can narrow the leap of faith to be more of a hop.

Healthy Travels!

Curtis J. Schroeder
Group Chief Executive Officer
Bumrungrad International
Bangkok, Thailand