More who need major surgery are leaving U.S. Overseas treatments sometimes carry extra risks, but can come at fraction of the expense

Bob Lupo reaches for his walker after riding his 2002 Harley Davidson for the first time since having his hip replacement surgery, Monday April 28, 2008, in Santa Rosa, Calif. After he was in a motorcycle accident he needed a hip replacement, because of being price and being uninsured he went to India for his transplant. Lacy Atkins / San Francisco Chronicle Ran on: 05-04-2008 Robert Lupo reaches for his walker after riding his motorcycle for the first time since having hip-replacement surgery in India. less Bob Lupo reaches for his walker after riding his 2002 Harley Davidson for the first time since having his hip replacement surgery, Monday April 28, 2008, in Santa Rosa, Calif. After he was in a motorcycle ... more Photo: Lacy Atkins Photo: Lacy Atkins Image 1 of / 1 Caption Close More who need major surgery are leaving U.S. 1 / 1 Back to Gallery

Robert Lupo of Santa Rosa had never been on an airplane until last month, when he flew to India to get his hip replaced.

The 45-year-old self-employed contractor had dropped his Kaiser coverage before an uninsured driver hit him last summer while he was riding his motorcycle. A $50,000 settlement covered those medical bills and living expenses while he was unable to work, but Lupo later learned he needed a hip replacement - a $30,000 price he couldn't afford.

With pain as his primary motivator, Lupo started researching his options online. He eventually found his way to WorldMed Assist, a 2-year-old Concord company that is part of a growing industry that makes arrangements for Americans to get medical care abroad.

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Lupo's hip surgery and hospital stay cost $8,880 at Wockhardt Hospital in Bangalore. Even with the $1,300 airfare, the procedure totaled about a third of what it would have cost Lupo at a local hospital.

"My hip feels great," said Lupo, who was recovering at home while making magnets out of photographs from India to send back to the nurses and hospital staff in Bangalore. "But I really don't want to go to another Third World country again, to tell you the truth, unless I had to. This was a means to an end. But the pain was so bad I would have swum the English Channel if that's what it took."

No official statistics are kept on how many Americans travel overseas for medical care, but one estimate places the number at 150,000 in 2006.

Other trends are more clear-cut. Many Americans are uninsured - nearly 47 million at last count - and others have health insurance that does not adequately cover procedures they desperately want or need.

A medical tourism industry has grown to facilitate global health travel. A trade association to represent these companies formed last year. Also last year, a major insurer started a separate company to help members seek international care.

Crossing international borders for medical care is not new. For decades, Americans have sought certain types of care in other countries, specifically elective or cosmetic procedures, along with treatments that are not approved by the U.S. Food and Drug Administration.

But now, industry experts say, Americans are going overseas for increasingly complex surgeries. In addition, more patients seem willing to accept that quality of care in some foreign hospitals may be the same or higher as that found on U.S. soil, at a fraction of the cost.

Wouter Hoeberechts, chief executive of WorldMed Assist, doesn't like the term medical tourism because he says it trivializes the industry by conjuring up images of post-operative patients recuperating on the beach drinking margaritas.

"Typically, what we have seen is people who want to save money - who don't have insurance or have poor insurance," he said, adding that his company is paid by the international hospital rather than by patient fees. "But we're seeing a shift where it's not just all about money. Quality is becoming very important."

Huge savings involved

Unquestionably, the price differential is the main draw.

Heart bypass surgery, which can cost more than $130,000 in the United States, can be performed for $10,000 in India and $19,000 in Turkey. Gastric bypass surgery, typically $18,000 to $25,000, can be done for $10,000 to $15,000 in many other countries, while the newer "lap band" procedure, which costs about $16,000 here, can be performed for half that price in countries like Mexico and Turkey.

Hoeberechts' company recently arranged for a Florida landscaper to have a liver transplant expected to cost $350,000 in the United States for just $55,000 in India.

But will the quality of care be as good as here at home? That depends on whom you talk to. Industry experts recommend going to foreign hospitals with recognized international accreditation, such as from Joint Commission International or the International Society for Quality in Health Care Inc.

WorldMed Assist, for example, works with just five hospital groups in four countries, all of which are certified by Joint Commission International, a nonprofit U.S. organization that accredits overseas hospitals. A native of The Netherlands, Hoeberechts said his company does not work with facilities in countries that permit citizens to donate organs to foreigners.

American physicians warn that patients who seek care overseas for complex procedures such as orthopedic surgeries may underestimate the potential for something to go wrong, both overseas and upon their return.

"Everything is made in China now. It doesn't have to be that way for health care," said Dr. Robert Klapper, chief of orthopedic surgery at Cedars-Sinai Medical Center in Los Angeles and spokesman for the American Academy of Orthopaedic Surgeons. "You take major risks when you go elsewhere."

Klapper admitted he typically ends up seeing only those who run into trouble but said that such complications happen and that puts local surgeons at a disadvantage because they lack information about the procedure.

Fresno surgeon Kelvin Higa, president of the American Society for Metabolic and Bariatric Surgery, said that in addition to wanting to save money, patients often travel overseas out of frustration because health insurance carriers make it so difficult for them to get surgery for obesity.

While he does not recommend going overseas for care unless patients have no alternatives, he said he understands the allure of the savings.

"I outsource my dictation to India because of the price difference. I understand medical tourism," he said. "Adjustable banding is half the price in Tijuana than it is San Diego. If the company sells the lap band to Mexico for a third of what they sell it to a United States hospital, how can you compete with that?"

The medical tourism industry typically caters to those who do not have insurance or whose insurance will not cover the treatment they seek. But one major insurer - Blue Cross and Blue Shield of South Carolina - last year became the first U.S. health plan to form a subsidiary to help its members seek care abroad.

Companion Global Healthcare works with major employers to offer employee members the option of seeking health care abroad at one of its seven partner hospitals accredited by Joint Commission International. The benefit is a cost savings to primarily companies that are self-insured, meaning those firms that take on the risk of medical costs incurred by their employees.

A companion plan

Still in its infancy, Companion Global Healthcare has served only three patients, said David Boucher, assistant vice president of health care services for Blue Cross and Blue Shield of South Carolina and Companion Global Healthcare.

"We're not sending people out of the country. We know an increasing number of members are going out of the country for care; what we're trying to do is make it a little easier for them if they choose to do it," said Boucher, adding that he thinks the service will take off if employers provide financial incentives for patients to choose overseas care.

A trade group for the growing industry, the Medical Tourism Association, was formed last year to help protect the reputation of quality businesses that help people seek care overseas as well as provide standards and guidelines, said Renee-Marie Stephano, general counsel and chief operating officer for the group, which has just 12 facilitator members.

"We establish a series of best practices and we have ethical guidelines. We promote the highest quality of care so any unethical behavior would not be tolerated," said Stephano, adding the group does not condone such practices as commercial surrogacy, organ selling and some unapproved treatments for life-threatening conditions.

Lupo, who otherwise would not have been able to afford surgery, praised the quality of care by the nurses and doctors in the Bangalore hospital, which he said was every bit as modern as an American facility.

His new hip was more than worth the 28-hour travel time, the occasional mosquito in his hospital room and the fight with a taxi driver who tried to take him to his uncle's rug shop instead of his destination, he said. The experience also gave him a greater appreciation of life at home.

"We've got a lot of stuff that's wrong here," Lupo said. "I left here thinking this really sucks that I have to go to another country to get hip surgery because I can't afford it. But after I got it done and got back, I realized we don't really have it that bad."

Medical procedures without borders More Americans are going overseas for health care. Here are tips when considering having surgery performed abroad: -- Research your alternatives, starting with exhausting the possibility of getting care in the United States and whether it's worth getting treatment elsewhere. The procedure must be expensive enough to make the trip worthwhile, considering the added costs of travel and accommodations. It also must have a relatively short recovery time and predictable follow-up care. -- Consider working with a company that can facilitate the care, travel and transfer of medical documents and other information. -- Investigate the background and training of the surgeon as well as the quality of the foreign hospital. Avoid politically unstable countries. -- Make sure follow-up care is available upon your return. For those with coverage, insurance may or may not cover the cost of post-operative care or complications associated with procedures performed overseas. Here are some Web sites to visit for more information: Medical Travel Authority: medicaltravelauthority.com Medical Tourism Insight: medicaltourisminsight.com Medical Nomad: medicalnomad.com Joint Commission International: jointcommissioninternational.org WorldMed Assist: worldmedassist.com Source: Chronicle research.