Ethical Considerations for Global Healthcare Benefit Plans

Evaluation of a global healthcare option program addresses emerging ethical dilemmas faced by US executives

Members of the various management societies typically have codes of ethics they agree to abide by, this is in addition to the ethics code of their company or organization. For executives responsible for healthcare benefits, an interesting question arises as to whether the ethics of the medical profession apply to the members of management societies who are not directly involved in the healthcare industry? I believe the answer is yes, because helping the employer control costs through the provision of healthcare benefits is so completely intertwined with the employees livelihood, wellness and family...and is emerging to be a profound management challenge.

Those in management positions in every company should be familiar with medical ethics and the impact those principals have on employer decisions concerning health benefits programs. There are four encompassing principals in medical ethics: respect for persons, beneficence, non maleficence, and justice.

Respect. This principle is characterized by autonomy, truth-telling, confidentiality and fidelity. Autonomy means that each patient has the right to determine his or her own treatment. This principle underlies the concept of informed consent, which require that patients have the information and understanding necessary to govern their own medical decisions.

While there is no question that the US has the best healthcare in the world, information about the quality of physicians and hospitals is nearly impossible to determine. Providing information to employees about medical options overseas, especially for those procedures required by an employee whose medical outcomes are vastly superior to those available locally. The provision of a global healthcare option enables the employee to balance the various factors, and make an informed choice about their healthcare.

Autonomy does not exist if the employee is not informed completely, and is "led" to a conclusion someone else wants. A good example of this is the emerging ethical dilemma caused by corporate programs that offer "in-country medical tourism." In an attempt to reign in corporate benefit costs, companies have emerged to identify geographically far flung hospitals and physicians willing to offer steep discounts to increase volume. This is potentially an unethical business practice for two reasons: 1) the hospital and doctor are deeply discounting prices because their volumes are lower than required for proficiency, and perhaps not being forthcoming about medical outcomes and 2) the corporation is "leading" an employee to make a cost effective decision for the benefit of the company, and potentially exposing the employee to an increased medical risk.

Truth-telling dictates that the professional tell the whole truth, not a half-truth or a "white lie." Employer truth-telling concerning coverage of specific healthcare benefits is crucial. It is imperative that the corporation exert every available effort to document the medical outcome that an employee may expect to experience for a given surgeon/hospital combination. For example, it is critical to know that a US board certified orthopedic surgeon who has performed 400 hip surgeries with a 99.5% success rate and no complications in Bangalore is certainly an option to be made available, especially when the local orthopedic surgeon has performed 40, and the hospital is trying to address a concerning number of MRSA infections.

Fidelity is simply defined as keeping your promises. But are you keeping the promises made in your healthcare benefits program by not systematically scouring the industry for options? Many times, we are led to believe that this vigilance can be 'outsourced' to a consulting or benefits management firm. A myopic view does not provide absolution from this responsibility.

Beneficence involves acting in the best interests of the employee/patient. This requires that the professional do all they can to aid the patient. Coming to a hasty conclusion that a global healthcare benefits program will not be well received deprives an employee of a critical option that can be considered along with other treatment possibilities in the US.

Non-maleficence is derived from the Hippocratic Oath, which includes the statement, "First, do no harm." Health professionals are expected to recommend and provide treatment that is likely beneficial and to specifically avoid treatment that may prove harmful. Allowing or requiring that an employee undertake healthcare from a practitioner that recommends unnecessary treatment is maleficent because it exposes the patient to risks and costs of treatments. Examples of decisions that have demonstrated this principle of non-maleficence I have seen among the hundreds of patients we have sent to India include:

• A bilateral hip replacement was recommended by a local US surgeon. After consultation, the Indian surgeon performed a hip resurfacing procedure...which relieved the pain in the non-surgical hip.
• A hip replacement was recommended by a local US surgeon. After consultation and complete medical workup, the Indian surgeon determined that a large spinal tumor at the base of the skull was the proximate cause of the patients pain. The tumor was successfully removed, and hip pain alleviated...sparing the patient from an unnecessary hip replacement surgery.
• Several obese patients were on a vast array of medications for diabetes control, joint pain and being treated for symptoms simply related to their obesity. Several had surgery scheduled for joint replacement. A complete medical workup followed by bariatric surgery has resulted in the loss of hundreds of pounds, complete avoidance of additional orthopedic surgery, and in most cases, a complete retreat of diabetic disease.

Further, these maleficent actions expend resources on patient resources that might be put to a different use. Corporate America is nearing the end of its ability to transfer healthcare costs to employees...and yet there is another tidal wave of costs emanating from the Obama healthcare legislation. It is more imperative now than ever for that corporate benefits executive expand their view outside the box.

Justice refers to actions that are impartial, fair and equal. Justice has applicability not only to the care of the individual employee/patient but also to making resource allocation decisions that are now required daily by the employer.

So how then does a global healthcare option program support the ethical responsibilities of the benefit executive?

1. The employee is provided the autonomy of making an informed decisions with multiple options
2. The employee is told the complete truth about a particular procedures, and the medical outcomes of the providers in the program, both in the US and India.
3. The corporation demonstrates fidelity to the benefit program, and actually delivers more than promised
4. The corporation has acted beneficently by examining the best options all over the world, rather than those that are locally expedient.
5. The corporation protects the employee from maleficence, by challenging the opinions of local healthcare practitioners from world class medical experts.
6. The well conceived global healthcare benefit program can demonstrate to a critical audience that justice has been fairly served to the employees.

So in addition to a global healthcare benefit program making sound economic sense, we find that it is also an ethical business decision.

Insurers Push Plans Limiting Patient Choice of Doctors and Hospitals

The inevitable reduction of physician/hospital choice begins as employers redistribute the cost burden of the Obama healthcare legislation to their employees.

Back in July of 2009, I predicted what effects the Obama healthcare legislation would have on a consumer/employees ability to choose their physician. Unfortunately, I was correct. The July 18, 2010 New York Times reveals that the country's biggest insurers are promoting plans with reduced premiums that require participants to use a narrower selection of doctors or hospitals.

The trade off, they say, for these reduced price plans, is that more Americans will be asked to pay higher prices for the privilege of choosing or keeping their own doctors if they are outside the new networks. Surprise! Remember the repeated assurances from Obama that consumers would retain a variety of healthcare choices?

But choice - or at least choice that will not cost you dearly - is likely to be increasingly scarce as health insurers and employers scramble to find ways of keeping premiums from becoming unaffordable. Aetna, Cigna, United and WellPoint are all trying out plans with more limited networks.

The size of these networks is typically much smaller than traditional plans. In New York, for example, Aetna offers a narrow-network plan that has about half the doctors and two-thirds of the hospitals the insurer typically offers. People enrolled in this plan are covered only if they go to a doctor or hospital within network, but seeing physicians and hospitals outside the network will pay much more for the privilege.

With families paying an average of $13,000 annually for medical coverage, it is quite possible that with co-pays and deductibles, the premium penalty for choosing a top-tier physician and hospital might actually begin to eclipse that package rates of the identical procedure performed in India.

The choice will then between a local US physician/hospital whose medical outcomes are impossible to determine, versus a world renowned surgeon/super specialty hospital in India.

Transformational Healthcare

Data from hundreds of successful surgical procedures in India yield some surprising results

If you happened to watch the LPGA Womens Open this weekend, it is unlikely you would have noticed the effortless way that caddy Fred Schuler walked the course. It is difficult to imagine that earlier in 2009 he had collapsed on a golf course in Canada due to excruciating back pain. He could not walk upright, ride in a car...and was essentially unable to do much of anything without pain.

Working with IndUShealth and the surgical specialty team at Fortis Hospital in Bangalore, we arranged for an L3-L4 discectomy to be performed on October 29, 2009.

By March of 2010, he was able to run 2.5 miles, ride a bike for two hours, and resume caddying.

While there are many stories to tell about outstanding medical outcomes across the world every day, what is unique about the IndUShealth patient story is that hundreds of patients have experienced these outstanding results, with a 100% satisfaction rate...and dramatic cost savings.

There are dramatic differences between the way patients experience US vs Indian healthcare, and we now have enough patient data to draw some interesting conclusions.

The Indian physician focuses on healing the patient. Because of the way that the US physicians and hospitals are compensated for their services, it is impossible to escape the fragmentation of traditional healthcare. Every component of patient service is plucked and parceled out to a variety of practitioners, separated by time and distance. There is little time for any emotional bond to be made with a healthcare professional at any level.

In an Indian super specialty hospital, the US patient is the benefactor of having the complete attention of a physician who has vast experience, and whose medical judgement is not clouded by the financial distractions of their US counterparts. Rather than moving from procedure to procedure, the Indian physician must manage the individual healing process to such an extent that the patient can easily make the return trip to the US. This means that physical therapy starts immediately after surgery, and is continuous throughout the patient stay.

One important aspect of the healing process is not so easy to measure, and this the role that the patient plays in their own recovery. Patients who have confidence in their surgeons, and believe the surgeon is genuinely interested in their outcome have a better healthcare experience. The very simple act of an Indian surgeon giving a patient his cell phone number is a powerful example.

The entire journey to India is focused on healing. There is no question that it is a long trip from the US to India. And it is also indisputable that most of us in the US have a very low attention span, have little time to focus on specific tasks, and lead fragmented lives. A medical journey to India has the effect of focusing an individuals attention to the healing task at hand. The medical traveler has either been forced through life circumstances, or found the inspiration to think outside the 'US healthcare box' and commit to this decision. Many times their decision has been derided by colleagues at work, healthcare professionals in the US or myopic family members.

Another important distinction is that for some surgeries, such as bariatric, the Indian surgeon requires a patient to demonstrate committment to certain life changes prior to surgery. For example, smoking must stopped and certain weight targets must be met. This process begins an emotional investment in the patients healing process, which is typically absent in US system.

So quite unlike the meandering path experienced in the US, there is significant personal investment of time, energy and resources to the healing process in India.

The patient experiences a transformational healthcare milestone in their lives. For most of our patients, the trip to India is the first journey outside the US. This is a peak experience of world travel, exposure to new cultures, and being the benefactor of a 2600 year old healing tradition.

The Asymptomatic Condition

Whereby Indian-style prevention reveals that I am traveling with an impending massive heart attack, and its not my heart.

My extraordinary business partner and I were making our fourth business trip to India. Thanks to the British Airways strike, we were afforded a very comfortable 'four adjacent seats across' seating, and slept from Raleigh to London. The London to Bangalore flight was more typical, and we were greeted in the new Bangalore terminal. Quite the change from the old terminal, and representative of the welcoming progress throughout India.

Our first visit was at the Fortis (previously Wockhardt) Hospital, where we not only met with our friends and colleagues, but took advantage of the exhaustive Executive Healthcheck. In addition to a complete panel of blood work and imaging, we also completed cardiac stress tests. Although I must admit I do not get my heart rate up to the 158 target as often as I should, this old mule passed with flying colors.

We were quite surprised that my partner's test exhibited some unexpected and disturbing results. These were immediately reviewed by a cardiologist, who urged my colleague to schedule a cardiac cath while in Bangalore. This took us both by surprise, as he watches his weight, diet and gets exercise...and had never had any symptoms. He took the offer for a cardiac cath as typical Indian hospitality, and decided it best to discuss the operation with his wife upon his return to the US...with the intention of having the cath during his return trip to India in a few months.

Grateful to have this new bit of personal health information, we continued our journey on to Mumbai and Delhi over the next two weeks.

Upon his return to Raleigh, he casually asked a cardiologist friend to take a look at the stress test results. Upon reviewing them, he scheduled my colleague for a cath at Wake Med the next day.

The cath revealed one artery with a 90% blockage and another with a 99% blockage.

He was taken off to surgery for two new stents.

Later, we find out that diabeties commonly masks heart pain, and my colleague was no doubt having 'mini' heart attacks without even knowing. This story typically ends badly...the unsuspecting patient drops dead of a massive heart attack...to the surprise of the US physician and the patient's family and friends.

My colleague was scheduled for a cath at age 50...it is unlikely he would have made it.

Next, we will take a look at the cost of fixing this undiagnosed condition, and how it compares with the same procedure in India. The irony of this averted tragedy is sadly quite instructive.

Fast Access to Medical Care in India

Over the past few years, Medical Tourism has been associated with a somewhat leisurely consideration of healthcare options for mostly chronic conditions. But what happens when there is an immediate need for surgery?

It takes a tremendous amount of international coordination in order to meet the travel needs of each patient, and the exceptions that typically occur while traveling to the far side of the world. And while IndUShealth and their partners have exceeded the medical expectations for hundreds of patients, exceptions continue to be part of the routine.

While a more measured pace is usually desired, sometimes we are called to moving things along as quickly as possible.

12.28.09 The parents of a teenager on the east coast contacts IndUShealth about his required clavicle and shoulder surgery resulting from an injury which needs to take place within a couple of weeks based on the advice of a local specialist. The mom, dad and teenage patient did not have an Indian visa.

A miracle occurs.

01.11.10 Surgery in Bangalore