A Tale of 2 Countries: The Cost of My Mother’s Cardiac Care in the United States and India

Being a Health Systems Researcher and having obtained experience from US hospitals (Miami and Tucson)- I have some clear issues with the methodology and comparisons made in the Journal Article. First of all one cannot compare prices based on plain dollar terms as workforce payments clearly differ in developed and developing countries i.e. A doctor in the States clearly gets paid more than a doctor in India adding to the final costs. The Author also bases the comparison of the US Health System to the Indian Health System on the assumption that the funding mechanisms are the same in both systems. While significant component of both systems are private driven the fundamental difference is that there is Universal Health Care/Insurance in India while not so in the US. Medicare and Medicaid compensate select population brackets so does the VHA and Indian (Native American) Hospital service select groups. Largely individuals are dependent on employer provided medical insurance or purchased on their own. Also Insurance Providers recommend treatment through certain providers. There is some change occuring through the PPAC Act to improve insurance coverage but there is a long way to go.

Coming back to the article, which has identified certain gaps in the US Health System and extolled the advantages in Indian Health System. I can clearly argue the very same gaps can identified in the Private Indian Health systems, which largely caters to middle and upper class Indian leaving out significant chunk of Indian Population. The generalisability of the article is left to question.

Competing interests: None declared

Thanks Dr. Rao for a very true and insightful summary of your experience in the two countries. I have a similar story for my father's pacemaker surgery and my mother's bilateral knee replacements, both were performed in India (since my parents are 75+ and live in India). Excellent care and at low costs where we knew the costs upfront as a package price, we knew the expected length of stay in the hospital ahead of the procedures, and I could prepare in advance on how much leave I should take from my current job in the US to help them get back on their feet before I return to my work.

I am a trained Heart Surgeon from one of India's apex institutions in New Delhi, All India Institute of Medical Sciences (AIIMS). When I moved to US in 1988, I had to retrain here and was at the world famous Mayo Clinic, Rochester MN for several years. However, even though the technological advances in medical care are immense in the US, what is missing is the clinical acumen that we learn in India. During my medical school years at AIIMS, I learned how to diagnose illnesses often by observing the patient, their posture, their walk, hear their story etc.

Medical School education is very different in US, as I have twin daughters studying in premier institutions in this country where medical students are taught on standardized patients, and are asked to learn up a script for patient history taking. No wonder they don't learn clinical judgment, and they are taught to distance themselves from their patients. Medicine is an art and a science and we need to teach our students both.

As you rightly pointed out, transparency is missing from the US healthcare system, both in terms of costs and expected outcomes. An important emphasis is on avoiding law suits, so defensive medicine abounds and overuse of tests and procedures is the norm. In the US, it is all about technology, and medicine has been transformed from a service industry to a business where the goal appears not to be to do what is right by the patient, but to extract what you can out of another person's misfortune (due to illness or injury).

I agree when it comes to receiving care for your own family, I would any day rather go to India (if I had a choice) than get it in the US -- not so much for costs but also for outcomes. In US you don't know what outcomes to expect, most doctors are NOT patient advocates, and are most often worried about covering themselves, rather than doing what is right for the patient. In India, if you go to a trusted doctor, you know you will get personalized attention and you will get a desirable outcome.

Competing interests: None

Mr. Pathak

Thank you for your comments. The main point of the article is not just that high-quality medical care available in India is cheaper than in the US, but that it is transparent. Lack of transparency makes it difficult to plan financially for patients paying out-of-pocket for costs. A middle-class person in India can actually afford to purchase health-care for some pretty significant procedures, and they would know what they are paying up front, while here in the US it might very well bankrupt them. Not to mention the fact that they won't know what they are paying here until after the fact, when it is too late.

The US is indeed a leader on healthcare research and groundbreaking treatments, but the evidence shows we are behind much of even the developing world in healthcare delivery.

Sowmya R Rao

Competing interests: None declared

I wonder if Dr. Sowmya R. Rao will be willing to work at India salary rate here in US in her profession. If not then some Indian in US will tell her the same thing on her service fees. This is like me complaining about Rs. 70 samosa I eat here in US which is sold for Rs. 7 in India. US healthcare is driven by insurance companies, lawsuits laws and protection etc. Those machines in India that is making things easier to diagnose, operate and monitor are probably made in USA or other countries. US system may be complicated but far ahead in medical research and services. My 2 cents.

Competing interests: None declared

The author makes valid comparison between US and India. How does one continue to be able to provide good services in India when large numbers of doctors leave the country to study and make their careers elsewhere? How does one work towards improving the medical education system in India so people are able to get their education domestically, or at least return to work in the country?

Competing interests: None declared

Replace cardiac surgery for mother with thyroid surgery for wife. And Bangalore for Mumbai. And we have health insurance here in the United States. I hope that we do not have any need for any major procedure ever again, but if we do, we will pay for business class fare to India, get world-class care that is fast, efficient and much better than what we could get here. The cost might be higher for us (see reason below), but it is well worth it.

Why would be the costs higher in India for us? Because the insurance company, a privately-run organization that is supposed to have the nimbleness that a government-run organization lacks, went by the rule-book and considered the Indian hospital to be "out of network". Even though the cost to them was maybe a tenth of what they would pay if my wife had got the surgery done here in the US. I would have thought that the insurance companies would have paid me to visit their offices and share my experiences. Isn't that what private businesses run by titans of industry supposed to do? Lower costs, achieve higher customer satisfaction, deliver higher shareholder profits?

Competing interests: None declared

In the article, Dr Rao has well described one of the challenges faced in the United States by patients when seeking health care. Cost transparency is an important factor, which drives their decision-making.

My personal experience when I underwent radiofrequency ablation procedure for varicose veins had been similar, but nevertheless, I went ahead with the procedure. A rough estimate of out of pocket expenses was provided when I enquired, but the final invoice was quite different. Calling the billing department and the insurance company didn't help either. Being a health care provider myself, the experience left a bitter taste in my mouth. Since then, I have come across many patients including some of my own, who had to face identical circumstances. On several occasions, my patients have asked me about the cost involved in certain test or procedure. But there has been no instance when I or our support staff including those who work in the billing department have been able to provide a definitive answer. To my surprise, the patients have accepted this and it seems to me that they have made their peace with the ambiguity, as if there is no alternative.

India, on the other hand runs two parallel health systems - 'Government' and 'Private'. Government hospitals are highly subsidized and cost is rarely an issue, whereas treatments at private hospitals are expensive. Most patients don't have health insurance and they pay everything out of the pocket. Billing is simple and based on the facts mentioned by Dr Rao, and the patients are informed up front how much they have to pay. Direct payment by the patients is the predominant method of reimbursement, and this, quite possibly, is the main reason why everything is simplified. Costs for tests, medications, surgeries and procedures are fixed at any center and vary only between different hospitals. For the much smaller number of patients who do have insurance, this simplicity remains in place. Would it be different if payments came from a third party like it happens in US? Probably yes.

Billing in US is complex and overtly challenging, as it takes into account multiple factors like clinical documentation, appropriate coding of the diseases and actual face-to-face encounter time. Payments come from third parties and different insurance companies have different criteria for reimbursement. Various layers of people working in 'billing', 'coding', 'utilization review' and 'appeal' are usually involved who have to negotiate back and forth with insurance companies after the care has been provided. Clinical documentation plays a big part, which understandably varies with the care provider, but has to include certain points for a certain level of reimbursement. It's definitely not as straightforward as it seems. Overbilling and underpayments make things even more complicated. Keeping all of this in mind, I concur that providing transparency in cost for healthcare is probably too big a task.

As it turns out, it is often simple to be difficult, but difficult to be simple. Until we simplify things, this clarity about costs that the patients so often desire, will remain a distant dream. How do we make the big change, or for that matter, what are the changes that need to be made, so that patients can make informed decisions? I will leave this to the experts.

Competing interests: ?? None declared

Dear Dr. Ramamurti,

Thank you for your letter. I found your article very interesting too. I am hoping to create an awareness of this issue. I am surprised by the lack of comparative studies between developed and developing nations. Agreed that developed countries have more technologically advanced medical care but developing countries have to be innovative in their use of limited resources and also provide care to a population that cannot afford high prices. I hope developing countries maintain the good fundamentals while also incorporating the good advanced medical knowledge from developed countries and developed countries will learn some of the good aspects of delivering affordable care from developing countries.

Sowmya R Rao

Competing interests: None declared

Editorial note: Govindarajan corrected to Ramamurti on 26 Sept. 2014.