Bar-coded blood. Lipton urges patients to also ask a hospital how blood gets to the right patient. She strongly advocates a bar-coded bracelet or other wearable accessory that is scanned before a transfusion. At Wockhardt, which tracks blood in ledgers and on paper slips, there have been two near misses in which patient and blood did not match, says blood bank director Jyoti Balani. Both errors were caught in time, she says, and blood-borne infections are nonexistent. "We try to avoid transfusions," says Balani. "I can't remember any international patient in the last six months who needed blood." Banked blood comes largely from "replenishment donors"—local residents with a hospitalized relative are expected to donate. All blood is screened for HIV, hepatitis, syphilis, and malaria.
Joint-replacement patients are a special class in all hospitals because of the consequences of infection: An artificial joint that harbors a deep infection often must itself be replaced. For Barnum's operation, surgeon Sanjay Pai and his team, like those at good U.S. hospitals, sealed off their skin, even breathing filtered air pumped into hoods covering their heads. Wockhardt, like its competition, has to be persuaded to go public with its rates of postsurgical infection. Says Pradeep Thukral, head of international marketing, "Our competitors can claim that their data is better, and who can prove them wrong?" But the statistics are comparable to those of good U.S. hospitals—a 1.1 percent rate of surgical infection for heart-bypass patients, he says, and zero for joint replacements.
In Asia, nurses play a much smaller role in care than they do in U.S. hospitals. Emily Slaback, a former ICU nurse from Haslet, Texas, whose left hip and knee were replaced at Wockhardt in February, says they are more like nurse's aides. They are not expected to check patients as often or as closely, so patients have to take responsibility. Calling a doctor's attention to a bruise, for example, could prevent a bedsore that might become infected and prolong the stay. And while nurses who care for Americans are trained in English, their command is often incomplete. After his first surgery, Barnum was given a special mattress to prevent bedsores. He asked the nurses for the same mattress after his second surgery but couldn't make himself understood—or, as he says, perhaps they felt he didn't need it.
There would be no need for uninsured patients to go abroad at all, of course, if the prices they were quoted in the United States were more in line with what insurers and Medicare pay. In U.S. hospitals, the uninsured and wealthy foreigners are the major groups charged full price for an elective procedure. (People who come in through the ER for nonelective surgery will get a list-price bill, but few hospitals expect to be fully repaid.) There should be plenty of room for price cutting—for routine heart-bypass surgery in Texas, the list price is about $70,000 at one hospital in Abilene and $47,000 at one in Austin. But commercial health plans typically pay at least 60 percent below list. And Medicare pays even less—$18,609 to $23,589 on average for an uncomplicated bypass.
Would a U.S. hospital be willing to negotiate a heavily discounted price in advance with an individual patient? "If you go in and say, 'I'm paying for it myself, I'm not covered,' " says Richard Schirmer, vice president for healthcare policy analysis at the Texas Hospital Association, "they'll give you maybe 10 or 20 percent off if you pay cash upfront for the whole thing—at most, 20 percent off the rack rate." Rick Gundling, a vice president of the Healthcare Financial Management Association, which represents hospital financial administrators, can't name a hospital willing to go further, but he sees the day drawing closer. "Hospitals should embrace the retail market," he says. " As patients start calling around to shop prices, hospitals will have to start to compete on price, and medical tourism will add a whole new level of competition."