Surg Endosc (2014) 28:3329–3336 DOI 10.1007/s00464-014-3613-8
and Other Interventional Techniques
Medical tourism and bariatric surgery: who pays? Caroline E. Sheppard • Erica L. W. Lester • Anderson W. Chuck David H. Kim • Shahzeer Karmali • Christopher J. de Gara • Daniel W. Birch
•
Received: 3 April 2014 / Accepted: 5 May 2014 / Published online: 27 June 2014 Ó Springer Science+Business Media New York 2014
Abstract Introduction The objective of this study was to determine the short-term cost impact that medical tourism for bariatric surgery has on a public healthcare system. Due to long wait times for bariatric surgery services, Canadians are venturing to private clinics in other provinces/countries. Postoperative care in this population not only burdens the provincial health system with intervention costs required for complicated patients, but may also impact resources allotted to patients in the public clinic. Methods A chart review was performed from January 2009 to June 2013, which identified 62 medical tourists requiring costly interventions related to bariatric surgery. Secondarily, a survey was conducted to estimate the frequency of bariatric medical tourists presenting to general surgeons in Alberta, necessary interventions, and associated
Presented at the SAGES 2014 Annual Meeting, April 2–5, 2014, Salt Lake City, Utah. C. E. Sheppard S. Karmali D. W. Birch Faculty of Medicine & Dentistry, Centre for the Advancement of Minimally Invasive Surgery, Royal Alexandra Hospital, University of Alberta, Edmonton, AB, Canada E. L. W. Lester D. H. Kim C. J. de Gara (&) Faculty of Medicine & Dentistry, University of Alberta, Edmonton, AB, Canada e-mail: [email protected] A. W. Chuck Institute of Health Economics, University of Alberta, Edmonton, AB, Canada
costs. A threshold analysis was used to compare costs of medical tourism to those from our institution. Results A conservative cost estimate of $1.8 million CAD was calculated for all interventions in 62 medical tourists. The survey established that 25 Albertan general surgeons consulted 59 medical tourists per year: a cost of approximately $1 million CAD. Medical tourism was calculated to require a complication rate B28 % (average intervention cost of $37,000 per patient) to equate the cost of locally conducted surgery: a rate less than the current supported evidence. Conducting 250 primary bariatric surgeries in Alberta is approximately $1.9 million less than the modeled cost of treating 250 medical tourists returning to Alberta. Conclusions Medical tourism has a substantial impact on healthcare costs in Alberta. When compared to bariatric medical tourists, the complication rate for locally conducted surgery is less, and the cost of managing the complications is also much less. Therefore, we conclude that it is a better use of resources to conduct bariatric surgery for Albertan residents in Alberta than to fund patients to seek surgery out of province/country. Keywords Medical tourism Bariatric surgery Morbid obesity Costs
Medical tourism is defined as an individual intentionally traveling from their home province or country to receive medical care. A phenomenon often seen in Alberta is bariatric medical tourists (BMTs) returning to their home province to seek postoperative care. Bariatric surgery is the only evidence-based approach to excess weight loss. It has been illustrated to be a cost effective approach to the obesity epidemic [1–4]. There
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are numerous approaches to this surgery, with varying degrees of anatomical alterations. In this paper, we will discuss three common procedures. Considered to be the least evasive, adjustable gastric banding provides a removable partition of the stomach, creating a restriction that results in weight loss. Sleeve gastrectomy also facilitates weight loss by restriction, removing a portion of the stomach. Roux en-Y gastric bypass is considered that most invasive, with not only a restriction of the stomach, but also a shortening of the length of functional bowel that ingested food is exposed to for absorption. This rerouting of bowel also has effects on the endocrine system, causing this surgery to be especially effective at reducing excess weight [5, 6]. These three surgeries are the primary procedures conducted in the bariatrics program in Alberta, which provides publicly funded bariatric surgery. One hospital site of this program is the Royal Alexandra Hospital, located in the capital city of Edmonton. This program serves the district of Northern Alberta. The Royal Alexandra Hospital is a 678 bed facility, where 9,000–10,000 surgeries are conducted per annum, including 250 bariatric procedures. Bariatric surgical patients are enrolled in the Weight Wise clinic: a multidisciplinary team that assesses, supports, educates, and treats patients pre- and post-operatively. Often, medical tourist’s patients are seen post operatively in this clinic, while a portion are not. The estimated costs of medical tourism have begun to be explored [7]. However, the overall cost impact of this trend relative to the cost of publicly funded bariatric surgery in Alberta has yet to be described. In this study, we create a cost model for both of these modes of bariatric surgery in order to illustrate the most economical method of conducting these procedures.
Methods A conservative cost model was developed to evaluate and compare the costs of primary bariatric surgery patients in Alberta to bariatric medical tourists (Fig. 1). The analysis focused on direct costs to the healthcare system, such as physician time and interventions. No indirect costs, such as disability and loss of productivity, or costs to the patient, were included. Direct costs were obtained from the Department of Finance of Alberta Health Services (AHS) and the individual medical departments at the Royal Alexandra Hospital (RAH), Edmonton, AB, USA. Direct costs may vary between hospitals within Alberta, and between provinces. This cost model represents a conservative cost analysis, and denotes the minimum expenditures of both local and abroad bariatric surgery situations. Ethics approval was obtained through our institution’s local ethics board for collection of patient information.
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Preoperative care At the RAH, patients will remain on the surgical wait list for a median period of 12 months before surgery. During this time, patients work with the Weight Wise team to implement healthy lifestyle changes for weight loss and to undergo psychosocial assessment. While some weight loss is seen during these preoperative periods, it is our clinical experience that only after surgery do obesity related comorbidities begin to resolve. These patients will therefore incur a cost to the healthcare system by requiring treatments for diabetes, hypertension, and hyperlipidemia until these co-morbidities resolve. A literature search was performed to identify the direct cost of obesity to the Canadian healthcare system each year. Based on the median number of visits to the bariatric intervention team, a calculated cost of attending the clinic and remaining obese during this time interval was created using clinician billing for patients having surgery performed in Alberta. An additional literature search was performed to identify the waiting list for medical tourists, and the same direct obesity costs were applied. All dollar amounts calculated were converted into the equivalent 2013 Canadian dollar amount using an inflation calculator provided by the Bank of Canada [8]. Surgery Local surgery costs were obtained from the Department of Finance of AHS. These were based on averages of several hundred in-patient operative costs for each of the three bariatric procedures: laparoscopic sleeve gastrectomy (LSG), laparoscopic Roux-en-Y gastric bypass (LRYGB), and laparoscopic adjustable gastric band (LAGB). An average cost of BMT surgical expenditures was based on advertised online prices from abroad institutions, and literature on private clinic costs within Canada [9–12]. Private medical tourist costs were not included in the total cost to AHS, and only provided as a comparison to the public cost of surgery within Alberta. Complications A retrospective chart review of 601 primary bariatric procedures from 2009 to 2012 performed at the RAH was reviewed for early and late complications with associated interventions up to approximately 24 months follow-up. Complication costs were determined by costs of interventions, based on equipment costs and physician billing provided by the specific department where each intervention was performed (Diagnostic Imaging, Endoscopy, Surgical Suite, Pathology, Laboratory Medicine). An average of complication costs per patient per year was calculated [7].
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Fig. 1 Cost model for local versus abroad bariatric surgical treatment costs
A retrospective chart review of bariatric medical tourist patients, whom received intervention from January 2009 to July 2013 at the RAH, was performed. Records were only available from December 2009 to April 2013. Furthermore, a survey was created to identify the number of medical tourists seen by general surgeons in Alberta: the bariatric surgeons in our institution did not complete the survey. Of 225 surveys sent, with a response rate of 35 %, 57 on-call general surgeons responded, but only 25 fully answered the survey and saw medical tourists for acute complications. These 25 surgeons saw 59 BMTs during the year 2012–2013. The survey participants were asked to characterize the specific interventions ordered for this population. The same cost analysis that was used for local complications was used to calculate the cost of these interventions. Currently, no formal tracking system exists to identify Canadian BMTs. Therefore, survey and chart review of outpatient and inpatient records are the only available resources. An estimate of the ratio of BMTs experiencing complications was calculated based on the number of complicated patients from Alberta over a denominator of medical tourists. The denominator range was calculated using literature estimating the number of Canadian medical tourists, and
extrapolating the per-province number based on population density and resource demand [13]. In order to further validate the range of Albertan patients, several clinics were contacted to obtain an estimate of Albertan BMTs. The average cost for each presenting patient per year was applied to the established range of medical tourists. Reimbursement Reimbursement is available to claimants through AHS from two branches: the Out-of-Country Health Services Committee reimbursement and Out-of-Country or Out-of-Province reimbursement. The Out-of-Country Services Committee handles claims that physicians file on behalf of their patients for procedures that they would otherwise not be able to receive in Canada. The committee processes the claims on a case-bycase basis. While bariatric surgery has been a component of these claims, due to the sensitive nature of confidentiality with these claimants, costs were not available for research. Patient filed claims are processed by the Out-of-Country and Out-ofProvince reimbursement. These reimbursements cover the cost of physician time and compensation for hospital stay/ outpatient visits. Costs were compiled by a claims research analyst from Alberta Health Services. These claims may be submitted up to 1–2 years after the procedure was performed,
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and out-of-country claims may take an additional 1–2 years from submission of the claim to receive payment. Claims are comprised of anesthesiologist, surgeon, and surgical assist costs, ranging from $250 to $2,600. Separate claims are available for out-of-country in-hospital costs of which Alberta Health will compensate the patient for $100 per night in hospital and/or $50 per outpatient visit. Reimbursement data were provided for service dates equivalent to the medical tourism chart review. An average reimbursement per patient was calculated from the discrete number of recipients within each calendar year. Total analysis A summation of costs was performed for each branch of Fig. 1 to determine the total cost per patient per year to the Canadian healthcare system for local and abroad treatment. A decision analytic model was developed through Triage Version 2014 to determine the point at which, from an economic perspective, the cost of bariatric surgery would be a better use of resources if conducted locally versus abroad. A threshold analysis was created by varying the complication rate and costs of medical tourism. The main objective was to demonstrate the threshold at which this variation should impact resource allocation decisions.
Results Preoperative care A single study was found to have calculated the direct costs of obesity in Alberta in 2005. Their population sample was based on the 2004 Canadian Community Health Survey. The population of Alberta in 2004 was 3.2 million people, 25.2 % of which were obese, corresponding to a yearly direct healthcare cost of $404.2 million CAD and $640.85 per obese individual [14]. The bariatric team costs to prepare a patient for surgery were calculated to be $495.86 per patient. The search for private bariatric surgery literature led to a single article on wait times in public and private bariatric facilities in Canada; however, none could be found for private facilities abroad. Due to the lack of published information, several clinics were contacted to determine the wait times abroad. These wait times correlated with that found in the Canadian article of an average of 1 month before private bariatric surgery [9]. Surgery From 2009 to 2012, a total of 601 bariatric procedures were performed at the RAH of which 113 were LAGB ($10,470.90), 218 LRYGB ($17,882.96), and 270 LSG
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($11,934.17), equivalent to $8.3 million CAD and an average of $13,778.20 ± $3,129.05 per patient. Patient costs for private surgery were comparable at $11,084.75 ± $6,538.61. Complications Complication rates in our institution were determined. As per a chart review, complication rates for our institution from 2009 to 2012 were 16.6 % LAGB, 2.2 % LSG, and 20.8 % LRYGB. These include both immediate and late complications of all degrees of morbidity and cost, including weight gain, band removal, wound infection, and self-limited abdominal pain. The number of patients with complications seen in the medical tourist population was 74, leading to a complication rate of 12.3 %. A chart review from 2005 to 2010 of LAGB totaled a morbidity of 13.1 % [15]. LRYGB complications were 26.1 % of surgeries performed from 2005 to 2011 [16]. Between 2008 and 2011, a complication rate of 4.6 % was reported for LSG [17]. A comparison of immediate, late, and band complications for RAH from a chart review and medical tourists derived from the chart review and survey was calculated using the range in denominator (139–185) to determine the complication percentages (refer to Table 2). To compare these complication rates to those published, a North American literature search was performed to identify a range of immediate complication rates: Mexico 8.7–16.9 % acute complications and mortality 2 % [18–20], United States 2.9–11.3 % [21–23], and Canada 0–8.5 % (only LAGB available) [24, 25]. These rates vary depending on inclusion/ exclusion of various immediate or late complications. The only available literature estimating the number of Canadian medical tourists was from 2010, and was based upon interviews with medical tourism facilitators across Canada. These estimated numbers were not specific to bariatric surgery, and included orthopedic and cosmetic surgery [13]. However, not all patients approach a facilitator and may contact the clinic directly to initiate surgery. Therefore, the range of 1,000–1,400 provided in the article was used to estimate the number of possible bariatric tourists within Canada. This corresponds to a range of 115–161 individuals each year leaving Alberta for bariatric surgery. To verify this range, eight out-of-country and two Canadian private clinics were contacted regarding the number of bariatric procedures performed on Albertans. An estimated total number of 150 Albertan medical tourists for bariatric surgery per year was provided by clinic staff. Since this was near the upper limits of the range, a new range of 139-185, adjusted similarly to the publication, was used to conservatively estimate the denominator of patients. At our institution alone, we were able to conservatively identify 62 medical tourists from 2009 to 2013, two of which only required follow-up with the revision clinic. The
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Table 1 Cost model for local versus bariatric medical tourist treatment costs per patient Local (Alberta)
Medical tourism
Preoperative costs ($)
1,136.71
53.40
Surgery (avg $/patient)
13,778.20 ± 3,129.05
0.00
Complications (avg $/patient)
476.18 ± 67.54,
15,688.80–20,880.77
Reimbursement (avg $/patient)
0.00
1,927.52
Total ($)
15,391.09
17,669.72–22,861.70
cost of interventions for these BMTs was a total of $1.8 million CAD. An additional 59 medical tourists (2012–2013) were identified from the survey of general surgeons across Alberta, creating a total of 78 medical tourists requiring intervention each year due to bariatric surgery complications and follow-up. The total average cost of complications in this population was $37,210.61 per patient. This conservative estimation of both numerator and denominator of medical tourists creates a range for complication rates from 42.2 to 56.1 %. Together creating a cost of $15,688.80–$20,880.77 per medical tourist.
Fig. 2 Threshold analysis of complication rate for medical tourism in comparison to cost of local bariatric surgery. BMT bariatric medical tourist. Cost of bariatric medical tourism (BMT) as it varies with a change in complication rate is represented by ‘medical tourism’ line: points of intersection illustrate at what rate of complication BMT cost is equal to cost of local surgery. Light gray vertical line depicts estimated BMT complication rate range
Reimbursement Of the complicated patients returning to Alberta from the chart review and survey, 36.6 % were LSG, 25.6 % were LRYGB, and 37.8 % were LAGB in a given year. LAGB placement is not reimbursable by the government, however, a claim for an out-of-province band filling may be made. Band fill claim data were not available. However, claims for gastric partitioning and gastric bypass were available for both abroad and out-of-province. Length of stay was conservatively estimated based on local hospital stay after surgery. This amounted to a total of $916,469.65 CAD from January 2009 to July 2013, and an average of $1,927.52 per claimant.
Fig. 3 Threshold analysis of the cost of complication for medical tourism in comparison to cost of local bariatric surgery. Cost of bariatric medical tourism (BMT) as it varies with a change in complication cost is represented by ‘medical tourism’ line: points of intersection illustrate at what complication per patient BMT cost is equal to cost of local surgery. Light gray vertical line depicts average complication cost per BMT
medical tourism (Fig. 2), the cost of complications per medical tourist (Fig. 3), and the combined variation of complication rate and cost (Fig. 4).
Total analysis
Conclusions
Comparing all direct costs in similar populations of 250 local primary bariatric surgeries with a complication rate of 12.3 % and 250 medical tourists with a complication rate of 56.1 %, approximately $1.9 million more is spent on medical tourists. The number 250 was chosen, as it is approximately the number of bariatric surgeries budgeted for at our institution in 1 year, and thus more closely reflects annual cost. A summation of the cost model in Table 1 for local versus abroad surgery was performed. A variation was performed on the complication rate for
Medical tourism has a substantial impact on the cost of bariatric programs in Alberta. This impact has ramifications on our program limitations of government budgeted resources, complication management, and surgical wait lists. Medical tourism is a growing phenomenon, and as such our interaction with these complicated individuals has also increased. Patients travel for medical care for several different reasons, one of which being extensive wait lists in Canada. While the local surgical wait list is a median of 12 months and only 1 month to travel abroad, medical
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Fig. 4 Threshold analysis of varying complication rate and cost of complications to reach the equivalent in local bariatric surgery costs. Y-axis cost of complication, X-axis complication rate. Brief description: As complication rate and complication cost vary, each point along the curve represents the value for each at which total cost bariatric medical tourism equals average total cost of local surgery
Table 2 Breakdown of average complication rate for all three bariatric surgeries performed locally (2009–2012) versus complications in medical tourists Complication
Local (Alberta) (%) (n = 601)
Medical tourists (%) (n = 139–185)
Immediate complications Hemorrhage
2.3
0.2–0.2
Leak
0.3
12.8–17.0
DVT/PE Organ failure
0.3 0.0
1.2–1.7 0.5–0.7
Subtotal
2.9
14.7–19.6
Late complications Ulcer
3.3
1.2–1.7
Stricture
1.8
1.6–2.1
Hernia
1.8
1.2–1.7
Dysphagia
1.3
5.4–7.2
Malnutrition
0.0
2.2–2.9
Band removal
1.3
16.1–21.4
Band slip
0.2
12.0–15.9
Band erosion
0.2
2.3–3.0
Port site complication
0.7
0.5–0.7
Dysphagia
0.3
1.3–1.7
9.5
27.7–37.0
12.4
42.4–56.6
Subtotal Total
Number of complicated patients: local (74), medical tourists (78). Complication rate: number of established complications over n
tourists do not receive the pre- and postoperative education and lifestyle management for bariatric surgery. The multidisciplinary clinic approach to patient care, including psychosocial assessment, may be a determining factor for better outcomes [26]. In fact, the complication rate for medical tourism was estimated to be 42.2–56.1 %, which is substantially higher
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than the local complication rate (12.3 %). The complication rates for bands were approximately 3-4 times higher in the medical tourist group (Table 2). Furthermore, the leak rate is conservatively 43 times higher in the medical tourist group. Whether these rates are due to lack of postoperative patient education, surgical technique, or postoperative travel is unknown. Due to the severity of the complications, a larger number of investigations/interventions were required for medical tourists relative to local patients, and the cost of treating this population was significantly higher. However, since the denominator of medical tourists was an estimation from the literature and clinics, an analysis of the complication rate was conducted, determining the threshold at which the cost of the complication rate of medical tourism would equate to the average cost of bariatric surgery performed locally. Figure 2 demonstrated that the complication rate of medical tourism would need to be B28.0 % (below 42.2–56.1 %) or using the conservative estimate of a complication rate of 42.2 %, the cost of complications would need to be B$24,234.11 per complicated BMT (below $37,000) (Fig. 3). Looking at solely the surgery and complication costs, the average cost of bariatric medical tourism in Alberta is approximately $6 million CAD per year based on the cost model. The costs calculated herein do not include the costs of Albertans who remain obese on the waiting list for surgery, whose surgery now has an extensive waiting time due to Weight Wise resources being used to rectify complications of surgeries conducted abroad. Currently, a finite number of surgeries (primary and secondary) can be conducted through the bariatrics program per year, and this number does not increase when the number of complicated BMTs requiring surgery increases. Therefore, this cost is a broad yet conservative approximation, and only depicts the short-term costs associated with BMTs. Based on the same population number, local bariatric surgery costs approximately $4
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million CAD per year, leading to a $1.9 million difference in surgical costs. Canadian healthcare is a public and provincial government funded system. Each province is funded by the federal Health Canada budget, with the proportion of funding based on total population of the province. Therefore, hospital and intervention costs are based on the actual cost of the resources. Insurance companies and other private sectors play a negligible role in patient care. In addition to the cost of complications, patient reimbursement for medical tourism is available through AHS. On average a claimant receives approximately $2,000 for their bariatric surgery, equating to approximately 1/8 of the private cost of out-of-province surgery or 1/3 of out-ofcountry surgery. These claims can be tracked back to 1999, and may have been put into place due to the necessity for bariatric surgery yet poor resource availability in Alberta at that time. In fact, the RAH only began performing LAGB and LRYGB in 2005 and LSG in 2008. From January 2009 to July 2013, on average 128 medical tourists each year have received reimbursement from AHS. The total amount claimed and received by patients without adjusting for inflation was $2.4 million and $0.9 million, respectively. We conclude that it is a better use of resources to conduct bariatric surgery for Alberta residents in Alberta than to fund patients to seek surgery out-of-province/country. There are many ethical considerations within this phenomenon, which are beyond the scope of this analysis. Further directions of investigation should include ethics as well as the long-term follow-up of these patients.
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Furthermore, the complication cost derived from the survey is limited by the nature of the questionnaire, as it excludes patients seen in outpatient clinic i.e., in a nonemergent setting. In addition, no system exists at the RAH to distinguish complicated medical tourists from local patients in the emergency department or inpatient wards, other than reviewing clinic records for the chart review. Based on these estimates, the complication rate of medical tourism is determined to be the best conservative estimate with the available resources. We are currently formulating an action plan to track these patients within our institution, however, this will not enable us to track patients province wide. Another limitation is that this study only estimates the short-term costs, and not the cost of caring for bariatric medical tourists over time. Nor does it include a comparison of care for local versus medical tourist care over time. In addition, certain costs were not available to include in the complication costs and reimbursement, thus reducing the actual cost of medical tourism. In conclusion, the increased costs of a longer wait list, bariatric clinic, and surgery locally fail to offset the substantial costs of medical tourism, even when determined conservatively. Therefore, government policy makers should be cognizant of these unbudgeted costs to appropriately manage resources for bariatric surgery patients. Disclosures Ms. Sheppard, Dr. Lester, Dr. Chuck, and Mr. Kim have no conflicts of interest or financial ties to disclose. Drs. Karmali, de Gara, and Birch have contributions from Ethicon Johnson & Johnson and Stryker in the manner of surgical equipment for resident training.
Limitations The limiting factor to this study was the denominator of medical tourists. One of the difficulties in acquiring this number is that there are several routes via which patients can seek bariatric surgery. For example, some patients may speak to their family physician about surgery, some may not due to potential stigma [27], and others may not have a family physician (19.5 % of Albertans) [28]. In addition, patients may use a facilitator to contact clinics or they may contact the clinic themselves. Therefore, the only method to estimate this denominator of untracked patients was to contact private clinics for an estimated number of Albertans each year, and search the Canadian literature. However, no literature exists to date to identify medical tourism between provinces. An additional limitation is the conservative numerator of complicated medical tourists. Only 25 out of 225 Albertan surgeons answered the medical tourism survey fully, which creates a large gap in the number of potentially complicated medical tourists across Alberta.
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and Other Interventional Techniques
Medical tourism and bariatric surgery: who pays? Caroline E. Sheppard • Erica L. W. Lester • Anderson W. Chuck David H. Kim • Shahzeer Karmali • Christopher J. de Gara • Daniel W. Birch
•
Received: 3 April 2014 / Accepted: 5 May 2014 / Published online: 27 June 2014 Ó Springer Science+Business Media New York 2014
Abstract Introduction The objective of this study was to determine the short-term cost impact that medical tourism for bariatric surgery has on a public healthcare system. Due to long wait times for bariatric surgery services, Canadians are venturing to private clinics in other provinces/countries. Postoperative care in this population not only burdens the provincial health system with intervention costs required for complicated patients, but may also impact resources allotted to patients in the public clinic. Methods A chart review was performed from January 2009 to June 2013, which identified 62 medical tourists requiring costly interventions related to bariatric surgery. Secondarily, a survey was conducted to estimate the frequency of bariatric medical tourists presenting to general surgeons in Alberta, necessary interventions, and associated
Presented at the SAGES 2014 Annual Meeting, April 2–5, 2014, Salt Lake City, Utah. C. E. Sheppard S. Karmali D. W. Birch Faculty of Medicine & Dentistry, Centre for the Advancement of Minimally Invasive Surgery, Royal Alexandra Hospital, University of Alberta, Edmonton, AB, Canada E. L. W. Lester D. H. Kim C. J. de Gara (&) Faculty of Medicine & Dentistry, University of Alberta, Edmonton, AB, Canada e-mail: [email protected] A. W. Chuck Institute of Health Economics, University of Alberta, Edmonton, AB, Canada
costs. A threshold analysis was used to compare costs of medical tourism to those from our institution. Results A conservative cost estimate of $1.8 million CAD was calculated for all interventions in 62 medical tourists. The survey established that 25 Albertan general surgeons consulted 59 medical tourists per year: a cost of approximately $1 million CAD. Medical tourism was calculated to require a complication rate B28 % (average intervention cost of $37,000 per patient) to equate the cost of locally conducted surgery: a rate less than the current supported evidence. Conducting 250 primary bariatric surgeries in Alberta is approximately $1.9 million less than the modeled cost of treating 250 medical tourists returning to Alberta. Conclusions Medical tourism has a substantial impact on healthcare costs in Alberta. When compared to bariatric medical tourists, the complication rate for locally conducted surgery is less, and the cost of managing the complications is also much less. Therefore, we conclude that it is a better use of resources to conduct bariatric surgery for Albertan residents in Alberta than to fund patients to seek surgery out of province/country. Keywords Medical tourism Bariatric surgery Morbid obesity Costs
Medical tourism is defined as an individual intentionally traveling from their home province or country to receive medical care. A phenomenon often seen in Alberta is bariatric medical tourists (BMTs) returning to their home province to seek postoperative care. Bariatric surgery is the only evidence-based approach to excess weight loss. It has been illustrated to be a cost effective approach to the obesity epidemic [1–4]. There
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are numerous approaches to this surgery, with varying degrees of anatomical alterations. In this paper, we will discuss three common procedures. Considered to be the least evasive, adjustable gastric banding provides a removable partition of the stomach, creating a restriction that results in weight loss. Sleeve gastrectomy also facilitates weight loss by restriction, removing a portion of the stomach. Roux en-Y gastric bypass is considered that most invasive, with not only a restriction of the stomach, but also a shortening of the length of functional bowel that ingested food is exposed to for absorption. This rerouting of bowel also has effects on the endocrine system, causing this surgery to be especially effective at reducing excess weight [5, 6]. These three surgeries are the primary procedures conducted in the bariatrics program in Alberta, which provides publicly funded bariatric surgery. One hospital site of this program is the Royal Alexandra Hospital, located in the capital city of Edmonton. This program serves the district of Northern Alberta. The Royal Alexandra Hospital is a 678 bed facility, where 9,000–10,000 surgeries are conducted per annum, including 250 bariatric procedures. Bariatric surgical patients are enrolled in the Weight Wise clinic: a multidisciplinary team that assesses, supports, educates, and treats patients pre- and post-operatively. Often, medical tourist’s patients are seen post operatively in this clinic, while a portion are not. The estimated costs of medical tourism have begun to be explored [7]. However, the overall cost impact of this trend relative to the cost of publicly funded bariatric surgery in Alberta has yet to be described. In this study, we create a cost model for both of these modes of bariatric surgery in order to illustrate the most economical method of conducting these procedures.
Methods A conservative cost model was developed to evaluate and compare the costs of primary bariatric surgery patients in Alberta to bariatric medical tourists (Fig. 1). The analysis focused on direct costs to the healthcare system, such as physician time and interventions. No indirect costs, such as disability and loss of productivity, or costs to the patient, were included. Direct costs were obtained from the Department of Finance of Alberta Health Services (AHS) and the individual medical departments at the Royal Alexandra Hospital (RAH), Edmonton, AB, USA. Direct costs may vary between hospitals within Alberta, and between provinces. This cost model represents a conservative cost analysis, and denotes the minimum expenditures of both local and abroad bariatric surgery situations. Ethics approval was obtained through our institution’s local ethics board for collection of patient information.
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Preoperative care At the RAH, patients will remain on the surgical wait list for a median period of 12 months before surgery. During this time, patients work with the Weight Wise team to implement healthy lifestyle changes for weight loss and to undergo psychosocial assessment. While some weight loss is seen during these preoperative periods, it is our clinical experience that only after surgery do obesity related comorbidities begin to resolve. These patients will therefore incur a cost to the healthcare system by requiring treatments for diabetes, hypertension, and hyperlipidemia until these co-morbidities resolve. A literature search was performed to identify the direct cost of obesity to the Canadian healthcare system each year. Based on the median number of visits to the bariatric intervention team, a calculated cost of attending the clinic and remaining obese during this time interval was created using clinician billing for patients having surgery performed in Alberta. An additional literature search was performed to identify the waiting list for medical tourists, and the same direct obesity costs were applied. All dollar amounts calculated were converted into the equivalent 2013 Canadian dollar amount using an inflation calculator provided by the Bank of Canada [8]. Surgery Local surgery costs were obtained from the Department of Finance of AHS. These were based on averages of several hundred in-patient operative costs for each of the three bariatric procedures: laparoscopic sleeve gastrectomy (LSG), laparoscopic Roux-en-Y gastric bypass (LRYGB), and laparoscopic adjustable gastric band (LAGB). An average cost of BMT surgical expenditures was based on advertised online prices from abroad institutions, and literature on private clinic costs within Canada [9–12]. Private medical tourist costs were not included in the total cost to AHS, and only provided as a comparison to the public cost of surgery within Alberta. Complications A retrospective chart review of 601 primary bariatric procedures from 2009 to 2012 performed at the RAH was reviewed for early and late complications with associated interventions up to approximately 24 months follow-up. Complication costs were determined by costs of interventions, based on equipment costs and physician billing provided by the specific department where each intervention was performed (Diagnostic Imaging, Endoscopy, Surgical Suite, Pathology, Laboratory Medicine). An average of complication costs per patient per year was calculated [7].
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Fig. 1 Cost model for local versus abroad bariatric surgical treatment costs
A retrospective chart review of bariatric medical tourist patients, whom received intervention from January 2009 to July 2013 at the RAH, was performed. Records were only available from December 2009 to April 2013. Furthermore, a survey was created to identify the number of medical tourists seen by general surgeons in Alberta: the bariatric surgeons in our institution did not complete the survey. Of 225 surveys sent, with a response rate of 35 %, 57 on-call general surgeons responded, but only 25 fully answered the survey and saw medical tourists for acute complications. These 25 surgeons saw 59 BMTs during the year 2012–2013. The survey participants were asked to characterize the specific interventions ordered for this population. The same cost analysis that was used for local complications was used to calculate the cost of these interventions. Currently, no formal tracking system exists to identify Canadian BMTs. Therefore, survey and chart review of outpatient and inpatient records are the only available resources. An estimate of the ratio of BMTs experiencing complications was calculated based on the number of complicated patients from Alberta over a denominator of medical tourists. The denominator range was calculated using literature estimating the number of Canadian medical tourists, and
extrapolating the per-province number based on population density and resource demand [13]. In order to further validate the range of Albertan patients, several clinics were contacted to obtain an estimate of Albertan BMTs. The average cost for each presenting patient per year was applied to the established range of medical tourists. Reimbursement Reimbursement is available to claimants through AHS from two branches: the Out-of-Country Health Services Committee reimbursement and Out-of-Country or Out-of-Province reimbursement. The Out-of-Country Services Committee handles claims that physicians file on behalf of their patients for procedures that they would otherwise not be able to receive in Canada. The committee processes the claims on a case-bycase basis. While bariatric surgery has been a component of these claims, due to the sensitive nature of confidentiality with these claimants, costs were not available for research. Patient filed claims are processed by the Out-of-Country and Out-ofProvince reimbursement. These reimbursements cover the cost of physician time and compensation for hospital stay/ outpatient visits. Costs were compiled by a claims research analyst from Alberta Health Services. These claims may be submitted up to 1–2 years after the procedure was performed,
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and out-of-country claims may take an additional 1–2 years from submission of the claim to receive payment. Claims are comprised of anesthesiologist, surgeon, and surgical assist costs, ranging from $250 to $2,600. Separate claims are available for out-of-country in-hospital costs of which Alberta Health will compensate the patient for $100 per night in hospital and/or $50 per outpatient visit. Reimbursement data were provided for service dates equivalent to the medical tourism chart review. An average reimbursement per patient was calculated from the discrete number of recipients within each calendar year. Total analysis A summation of costs was performed for each branch of Fig. 1 to determine the total cost per patient per year to the Canadian healthcare system for local and abroad treatment. A decision analytic model was developed through Triage Version 2014 to determine the point at which, from an economic perspective, the cost of bariatric surgery would be a better use of resources if conducted locally versus abroad. A threshold analysis was created by varying the complication rate and costs of medical tourism. The main objective was to demonstrate the threshold at which this variation should impact resource allocation decisions.
Results Preoperative care A single study was found to have calculated the direct costs of obesity in Alberta in 2005. Their population sample was based on the 2004 Canadian Community Health Survey. The population of Alberta in 2004 was 3.2 million people, 25.2 % of which were obese, corresponding to a yearly direct healthcare cost of $404.2 million CAD and $640.85 per obese individual [14]. The bariatric team costs to prepare a patient for surgery were calculated to be $495.86 per patient. The search for private bariatric surgery literature led to a single article on wait times in public and private bariatric facilities in Canada; however, none could be found for private facilities abroad. Due to the lack of published information, several clinics were contacted to determine the wait times abroad. These wait times correlated with that found in the Canadian article of an average of 1 month before private bariatric surgery [9]. Surgery From 2009 to 2012, a total of 601 bariatric procedures were performed at the RAH of which 113 were LAGB ($10,470.90), 218 LRYGB ($17,882.96), and 270 LSG
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($11,934.17), equivalent to $8.3 million CAD and an average of $13,778.20 ± $3,129.05 per patient. Patient costs for private surgery were comparable at $11,084.75 ± $6,538.61. Complications Complication rates in our institution were determined. As per a chart review, complication rates for our institution from 2009 to 2012 were 16.6 % LAGB, 2.2 % LSG, and 20.8 % LRYGB. These include both immediate and late complications of all degrees of morbidity and cost, including weight gain, band removal, wound infection, and self-limited abdominal pain. The number of patients with complications seen in the medical tourist population was 74, leading to a complication rate of 12.3 %. A chart review from 2005 to 2010 of LAGB totaled a morbidity of 13.1 % [15]. LRYGB complications were 26.1 % of surgeries performed from 2005 to 2011 [16]. Between 2008 and 2011, a complication rate of 4.6 % was reported for LSG [17]. A comparison of immediate, late, and band complications for RAH from a chart review and medical tourists derived from the chart review and survey was calculated using the range in denominator (139–185) to determine the complication percentages (refer to Table 2). To compare these complication rates to those published, a North American literature search was performed to identify a range of immediate complication rates: Mexico 8.7–16.9 % acute complications and mortality 2 % [18–20], United States 2.9–11.3 % [21–23], and Canada 0–8.5 % (only LAGB available) [24, 25]. These rates vary depending on inclusion/ exclusion of various immediate or late complications. The only available literature estimating the number of Canadian medical tourists was from 2010, and was based upon interviews with medical tourism facilitators across Canada. These estimated numbers were not specific to bariatric surgery, and included orthopedic and cosmetic surgery [13]. However, not all patients approach a facilitator and may contact the clinic directly to initiate surgery. Therefore, the range of 1,000–1,400 provided in the article was used to estimate the number of possible bariatric tourists within Canada. This corresponds to a range of 115–161 individuals each year leaving Alberta for bariatric surgery. To verify this range, eight out-of-country and two Canadian private clinics were contacted regarding the number of bariatric procedures performed on Albertans. An estimated total number of 150 Albertan medical tourists for bariatric surgery per year was provided by clinic staff. Since this was near the upper limits of the range, a new range of 139-185, adjusted similarly to the publication, was used to conservatively estimate the denominator of patients. At our institution alone, we were able to conservatively identify 62 medical tourists from 2009 to 2013, two of which only required follow-up with the revision clinic. The
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Table 1 Cost model for local versus bariatric medical tourist treatment costs per patient Local (Alberta)
Medical tourism
Preoperative costs ($)
1,136.71
53.40
Surgery (avg $/patient)
13,778.20 ± 3,129.05
0.00
Complications (avg $/patient)
476.18 ± 67.54,
15,688.80–20,880.77
Reimbursement (avg $/patient)
0.00
1,927.52
Total ($)
15,391.09
17,669.72–22,861.70
cost of interventions for these BMTs was a total of $1.8 million CAD. An additional 59 medical tourists (2012–2013) were identified from the survey of general surgeons across Alberta, creating a total of 78 medical tourists requiring intervention each year due to bariatric surgery complications and follow-up. The total average cost of complications in this population was $37,210.61 per patient. This conservative estimation of both numerator and denominator of medical tourists creates a range for complication rates from 42.2 to 56.1 %. Together creating a cost of $15,688.80–$20,880.77 per medical tourist.
Fig. 2 Threshold analysis of complication rate for medical tourism in comparison to cost of local bariatric surgery. BMT bariatric medical tourist. Cost of bariatric medical tourism (BMT) as it varies with a change in complication rate is represented by ‘medical tourism’ line: points of intersection illustrate at what rate of complication BMT cost is equal to cost of local surgery. Light gray vertical line depicts estimated BMT complication rate range
Reimbursement Of the complicated patients returning to Alberta from the chart review and survey, 36.6 % were LSG, 25.6 % were LRYGB, and 37.8 % were LAGB in a given year. LAGB placement is not reimbursable by the government, however, a claim for an out-of-province band filling may be made. Band fill claim data were not available. However, claims for gastric partitioning and gastric bypass were available for both abroad and out-of-province. Length of stay was conservatively estimated based on local hospital stay after surgery. This amounted to a total of $916,469.65 CAD from January 2009 to July 2013, and an average of $1,927.52 per claimant.
Fig. 3 Threshold analysis of the cost of complication for medical tourism in comparison to cost of local bariatric surgery. Cost of bariatric medical tourism (BMT) as it varies with a change in complication cost is represented by ‘medical tourism’ line: points of intersection illustrate at what complication per patient BMT cost is equal to cost of local surgery. Light gray vertical line depicts average complication cost per BMT
medical tourism (Fig. 2), the cost of complications per medical tourist (Fig. 3), and the combined variation of complication rate and cost (Fig. 4).
Total analysis
Conclusions
Comparing all direct costs in similar populations of 250 local primary bariatric surgeries with a complication rate of 12.3 % and 250 medical tourists with a complication rate of 56.1 %, approximately $1.9 million more is spent on medical tourists. The number 250 was chosen, as it is approximately the number of bariatric surgeries budgeted for at our institution in 1 year, and thus more closely reflects annual cost. A summation of the cost model in Table 1 for local versus abroad surgery was performed. A variation was performed on the complication rate for
Medical tourism has a substantial impact on the cost of bariatric programs in Alberta. This impact has ramifications on our program limitations of government budgeted resources, complication management, and surgical wait lists. Medical tourism is a growing phenomenon, and as such our interaction with these complicated individuals has also increased. Patients travel for medical care for several different reasons, one of which being extensive wait lists in Canada. While the local surgical wait list is a median of 12 months and only 1 month to travel abroad, medical
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Fig. 4 Threshold analysis of varying complication rate and cost of complications to reach the equivalent in local bariatric surgery costs. Y-axis cost of complication, X-axis complication rate. Brief description: As complication rate and complication cost vary, each point along the curve represents the value for each at which total cost bariatric medical tourism equals average total cost of local surgery
Table 2 Breakdown of average complication rate for all three bariatric surgeries performed locally (2009–2012) versus complications in medical tourists Complication
Local (Alberta) (%) (n = 601)
Medical tourists (%) (n = 139–185)
Immediate complications Hemorrhage
2.3
0.2–0.2
Leak
0.3
12.8–17.0
DVT/PE Organ failure
0.3 0.0
1.2–1.7 0.5–0.7
Subtotal
2.9
14.7–19.6
Late complications Ulcer
3.3
1.2–1.7
Stricture
1.8
1.6–2.1
Hernia
1.8
1.2–1.7
Dysphagia
1.3
5.4–7.2
Malnutrition
0.0
2.2–2.9
Band removal
1.3
16.1–21.4
Band slip
0.2
12.0–15.9
Band erosion
0.2
2.3–3.0
Port site complication
0.7
0.5–0.7
Dysphagia
0.3
1.3–1.7
9.5
27.7–37.0
12.4
42.4–56.6
Subtotal Total
Number of complicated patients: local (74), medical tourists (78). Complication rate: number of established complications over n
tourists do not receive the pre- and postoperative education and lifestyle management for bariatric surgery. The multidisciplinary clinic approach to patient care, including psychosocial assessment, may be a determining factor for better outcomes [26]. In fact, the complication rate for medical tourism was estimated to be 42.2–56.1 %, which is substantially higher
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than the local complication rate (12.3 %). The complication rates for bands were approximately 3-4 times higher in the medical tourist group (Table 2). Furthermore, the leak rate is conservatively 43 times higher in the medical tourist group. Whether these rates are due to lack of postoperative patient education, surgical technique, or postoperative travel is unknown. Due to the severity of the complications, a larger number of investigations/interventions were required for medical tourists relative to local patients, and the cost of treating this population was significantly higher. However, since the denominator of medical tourists was an estimation from the literature and clinics, an analysis of the complication rate was conducted, determining the threshold at which the cost of the complication rate of medical tourism would equate to the average cost of bariatric surgery performed locally. Figure 2 demonstrated that the complication rate of medical tourism would need to be B28.0 % (below 42.2–56.1 %) or using the conservative estimate of a complication rate of 42.2 %, the cost of complications would need to be B$24,234.11 per complicated BMT (below $37,000) (Fig. 3). Looking at solely the surgery and complication costs, the average cost of bariatric medical tourism in Alberta is approximately $6 million CAD per year based on the cost model. The costs calculated herein do not include the costs of Albertans who remain obese on the waiting list for surgery, whose surgery now has an extensive waiting time due to Weight Wise resources being used to rectify complications of surgeries conducted abroad. Currently, a finite number of surgeries (primary and secondary) can be conducted through the bariatrics program per year, and this number does not increase when the number of complicated BMTs requiring surgery increases. Therefore, this cost is a broad yet conservative approximation, and only depicts the short-term costs associated with BMTs. Based on the same population number, local bariatric surgery costs approximately $4
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million CAD per year, leading to a $1.9 million difference in surgical costs. Canadian healthcare is a public and provincial government funded system. Each province is funded by the federal Health Canada budget, with the proportion of funding based on total population of the province. Therefore, hospital and intervention costs are based on the actual cost of the resources. Insurance companies and other private sectors play a negligible role in patient care. In addition to the cost of complications, patient reimbursement for medical tourism is available through AHS. On average a claimant receives approximately $2,000 for their bariatric surgery, equating to approximately 1/8 of the private cost of out-of-province surgery or 1/3 of out-ofcountry surgery. These claims can be tracked back to 1999, and may have been put into place due to the necessity for bariatric surgery yet poor resource availability in Alberta at that time. In fact, the RAH only began performing LAGB and LRYGB in 2005 and LSG in 2008. From January 2009 to July 2013, on average 128 medical tourists each year have received reimbursement from AHS. The total amount claimed and received by patients without adjusting for inflation was $2.4 million and $0.9 million, respectively. We conclude that it is a better use of resources to conduct bariatric surgery for Alberta residents in Alberta than to fund patients to seek surgery out-of-province/country. There are many ethical considerations within this phenomenon, which are beyond the scope of this analysis. Further directions of investigation should include ethics as well as the long-term follow-up of these patients.
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Furthermore, the complication cost derived from the survey is limited by the nature of the questionnaire, as it excludes patients seen in outpatient clinic i.e., in a nonemergent setting. In addition, no system exists at the RAH to distinguish complicated medical tourists from local patients in the emergency department or inpatient wards, other than reviewing clinic records for the chart review. Based on these estimates, the complication rate of medical tourism is determined to be the best conservative estimate with the available resources. We are currently formulating an action plan to track these patients within our institution, however, this will not enable us to track patients province wide. Another limitation is that this study only estimates the short-term costs, and not the cost of caring for bariatric medical tourists over time. Nor does it include a comparison of care for local versus medical tourist care over time. In addition, certain costs were not available to include in the complication costs and reimbursement, thus reducing the actual cost of medical tourism. In conclusion, the increased costs of a longer wait list, bariatric clinic, and surgery locally fail to offset the substantial costs of medical tourism, even when determined conservatively. Therefore, government policy makers should be cognizant of these unbudgeted costs to appropriately manage resources for bariatric surgery patients. Disclosures Ms. Sheppard, Dr. Lester, Dr. Chuck, and Mr. Kim have no conflicts of interest or financial ties to disclose. Drs. Karmali, de Gara, and Birch have contributions from Ethicon Johnson & Johnson and Stryker in the manner of surgical equipment for resident training.
Limitations The limiting factor to this study was the denominator of medical tourists. One of the difficulties in acquiring this number is that there are several routes via which patients can seek bariatric surgery. For example, some patients may speak to their family physician about surgery, some may not due to potential stigma [27], and others may not have a family physician (19.5 % of Albertans) [28]. In addition, patients may use a facilitator to contact clinics or they may contact the clinic themselves. Therefore, the only method to estimate this denominator of untracked patients was to contact private clinics for an estimated number of Albertans each year, and search the Canadian literature. However, no literature exists to date to identify medical tourism between provinces. An additional limitation is the conservative numerator of complicated medical tourists. Only 25 out of 225 Albertan surgeons answered the medical tourism survey fully, which creates a large gap in the number of potentially complicated medical tourists across Alberta.
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