“Medical Tourism”—Dangerous for Patients and Difficult to Manage for Surgeons in the United States

| September 21, 2010

Dear Readers:
Welcome to the September 2010 issue of Bariatric Times. I just returned from Long Beach, California, where I attended the 15th Annual International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO) meeting under the direction and organization of Dr. Mal Fobi. This was the first time the conference took place in the United States. I congratulate Dr. Fobi, Dr. Buchwald, and the IFSO leadership for a job well done. Nearly 1,000 surgeons from around the globe participated in this conference. One highlight was the Latin American session chaired by Dr. Luis Ibanez from Chile, which was conducted for the first time in the Spanish language, with the participation of nearly 100 surgeons from Spain, Portugal, and Latin America.

During the conference, I had the privilege to participate in a session entitled, “Ethics in Bariatric Surgery,” during which we discussed “medical tourism.” A dear colleague of mine from another country complained about statements made by speakers. He argued that it is difficult and often unfair that surgeons outside of the United States deal with patients who seek treatment for their obesity abroad in order to save money and then go back to the United States for follow up. I strongly agree with this view. Not only it is unfair, but it can also be life threatening and a financial burden for the hospital in the United States and the patient. On several occasions, we have had patients who had their bariatric procedures performed abroad arrive at our emergency room in critical condition. Repeated surgeries were followed by longer hospital stays, which resulted in bills that reached hundreds of thousands of dollars. This left the hospital seeking payment from patients who end up severely disabled and financially broke. A solution must be found to this problem since emergency rooms in the United States cannot reject patients who present in critical condition, regardless of whether or not they have insurance coverage or where their initial surgery was performed. I hope that American Society for Metabolic and Bariatric Surgery (ASMBS) will create a subcommittee to tackle the issue of “medical tourism” and resolve this conundrum. I am sure we will hear much more about this problem in years to come.

In this issue of Bariatric Times, Joe Nadglowski, Jr. gives us a brief description of the history and mission of the Obesity Action Coalition. There is one issue, however, that has not been addressed, and I would like to bring it to Joe’s attention. Current insurance policies, including Centers for Medicare and Medicaid Services (CMS), limit procedure choice by patients and surgeons. I am wondering why I cannot perform a sleeve gastrectomy in a patient with morbid obesity whom I consider a poor candidate for any of the currently approved procedures, such as laparoscopic adjustable gastric banding (LAGB), Roux-en-Y gastric bypass (RYGB), biliopancreatic diversion with duodenal switch (BPDDS), or vertical banded gastroplasty (VBG)? Why can a surgeon have the autonomy to choose and perform a Billroth I- II or a vagotomy and pyloroplasty when treating peptic ulcer disease and not have the same freedom to choose the procedure when treating morbid obesity? I believe that procedure selection should be made by the treating physician and patient—not by the insurance companies. This might become a legal issue by itself if surgeons and patients are forced to choose a procedure that is not the ideal one just because insurance has unilaterally decided not to cover it.

We are also pleased to include an interview of Dr. Ninh Nguyen who discusses the changes made by the American College of Surgeons (ACS) Bariatric Surgery Center Network (BSCN) accreditation program. My clinic has accreditations from both the ACS and Surgical Review Corporation (SRC), but we had to drop the Level 1A because we could not afford to hire a nurse practitioner to enter data into the national surgical quality improvement program (NSQIP). At times when computers have inundated our lives and businesses, I hope that ACS can come up with a program that will allow us to enter and transfer data into NSQIP without the need to hire a full-time employee to complete the important job of data collection.
On a separate note, the IFSO-endorsed SRC International Center of Excellence accreditation program (ICE) was joined by the Mexican and Brazilian Societies of Bariatric and Metabolic Surgeons in the Center of Excellence (COE) and Bariatric Outcomes Longitudinal Database (BOLD) initiatives. Welcome aboard!

Next, David Mahony’s article on a standard preoperative psychological evaluation tool is an excellent read. I wonder what Dr. Mahony would recommend we do when a patient requests, due to religious reasons, not to undergo a psychological evaluation. Should and can we go ahead with surgery? I see patients with a flawless psychological evaluation fail and other patients with major psychological disorders succeed.

I would like to finish this editorial by congratulating Dr. Robin Blackstone, who was elected president of ASMBS, and Titus Duncan, who was elected the new secretary treasurer. I wish both of them the best of luck in their new positions and hope for a productive year.
See you at ACS 96th Annual Clinical Congress in Washington, DC!

Sincerely,

Raul J. Rosenthal, MD, FACS
Editor, Bariatric Times

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  1. Dear Raul:
    Medical tourism can be difficult with the patient and the surgeon, but this is a fact of today society. The patient will look for someone who will do the job for less.
    These phenomena most likely will increase and it happens today in a society where the cost of flying is real cheap. Not only on patients of the US move overseas to have their obesity being taken care of , we do have the same problem in Europe where this surgery has become quite expensive. Patients will travel to India, South America or somewhere else.
    The surgeons of the country of origin should also be aware that this is happening and I will highly recommend them to contact personally the surgeon who did perform the original operation and find out the operative report if possible, to help in this patients care. Today, I do this no matter from where does the patient comes from.
    I think that with this global surgical care the patients should also have more rights. Since we do this surgery most time by Lap we provided the DVD of the operation, extensive operative report and a discharge report to the patient. If a bariatric patient has problems later on, most likely he will consult a local physician or surgeon without any or significant information about his/her previous operation. Sometimes this local MD is not even aware of this type of surgery and less so about the details of the operation. I know providing the DVD to the patient sound legally difficult or almost impossible, but since even the most standardized operation (let say the LSG, that sound simple) is done differently by most surgeons. Or the most complex ones like a LDS that many physicians or surgeons (even bariatric surgeons) are not aware of the long-term complications or management.
    Thank you Raul. It is a pleasure for giving me the opportunity to share my thoughts with you. Aniceto Baltasar. Alcoy. Spain