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Thursday, November 20, 2008

American Companies Building Hospitals in Mexico Near Border

Dorthea, 72, a retired bank teller, lives in Harlingen, Texas, a city of about 67,000 in the heart of the Rio Grande Valley. Like a lot of Texans, she's crossed the border to Mexico a few times to buy cheap medication. But she'd never considered undergoing complicated medical procedures there—at least, not until she was quoted the prohibitive price of $30,000 for a gastric-band procedure, a treatment for obesity in which a band is placed around the stomach to limit food intake. It wasn't covered by her insurance, so Dorthea, who asked that her last name be withheld for privacy reasons, opted to drive south and pay less than $10,000 for the outpatient operation at an American-owned hospital in Reynosa, Mexico, 10 minutes over the border and about an hour from her home. The outpatient surgery was a success, and she's planning on returning for follow-up care. "It was very good treatment," she says.

Medical tourism, which used to be mainly for elective surgery, and aimed at people who could afford weeklong trips to Brazil, is becoming an increasingly viable source of more basic health care for some of those sidelined by the insurance system in America, where 47 million people are uninsured and many millions are underinsured. Now, Americans like Dorthea who live along the Mexican border are driving and even walking south in search of treatment that can cost half or less of what it does in the United States. In response, American hospital chains are starting to buy into Mexico; Dallas-based CHRISTUS Health has built six hospitals in Mexico, including the Reynosa facility Dorthea visited, through its partnership with a Mexican chain. Most of its doctors are Mexican with Mexican medical degrees.

The Mexican health-care option is particularly appealing for Texans because the state has such a high uninsured rate; it was 25 percent in 2004. Along the border, that number is even higher. Incomes in the area are low, too, so even when employers do offer insurance, the cost of medical premiums still may prohibitive for employees, according to a 2007 report prepared by Texas state authorities.

And though hospitals on the U.S. side pour hundreds of millions of dollars a year into charity care, they and other community health centers are strained. The Hope Family Health Center in McAllen—right across the border from Reynosa—sees from 50-100 uninsured patients a week, but always has a waiting list, says interim executive director Rebecca Ramirez, who adds that she has some family members who will drive to Mexico for their medical care.

Older Americans who live near the Mexican border have always crossed in search of dental care and pharmaceutical drugs, neither of which are fully covered by Medicare, according to Prof. David Warner, who studies cross-border health care at the University of Texas's LBJ School of Public Affairs.

This growing demand for lower-cost procedures is fueling an increase in hospital construction, often in developing countries and targeted in part at foreign customers. Mexico's largest private-hospital chain, Grupo Empresarial Angeles, is building 15 new hospitals over the next three years and hopes foreigners will make up 20 percent of their patients by 2010, up from 5 percent now.

American chains are getting into the act, too: International Hospital Corp. in Dallas has five Mexican locations, one close to the American border. And CHRISTUS, which bought a majority stake in Mexico's Grupo Muguerza in 2001, has grown a two-hospital chain to eight hospitals nationwide. CHRISTUS representatives say they're expanding to benefit Mexican patients but remain very aware of their increasing American clientele.

Procedures performed in CHRISTUS's Mexican locations cost a third to two-thirds less than they would in America. And when its biggest hospital, in Monterrey, became one of the first in Mexico to be accredited by the international Joint Commission (www.jointcommission.org), an independent nonprofit hospital-safety accreditation organization, its foreign patient load increased exponentially, from one patient a week to eight or nine. People come from as far away as Alaska in search of bariatric, plastic and cardiovascular procedures, as well as knee and hip replacements and hospital officials plan to start hiring more English-speaking staff, translators and concierge services, says Arturo Garza, CEO of the CHRISTUS Muguerza Group in Mexico. He expects the volume of American and other foreign medical tourists to only grow.

Americans already make up 30 percent of the patients at CHRISTUS's Reynosa facility, which opened this year and is not yet internationally accredited. "Reynosa's part of a cross-border strategy," says CHRISTUS CEO Dr. Thomas Royer. There are opportunities for similar hospitals to be built in about 40 other Mexican communities close to the American border. But the company is waiting to see how Mexican-American immigration policies develop before making any bold decisions, he says.

Insurers are looking into cross-border health care, as well. For years, Southern California's Blue Cross Blue Shield has offered a cross-border health insurance plan that grants drastically reduced premiums to patients who get certain procedures performed in Mexico. But not all proposals have been met with excitement: Texas state Sen. Eddie Lucio, who represents counties including Cameron and Hildago, last year proposed a bill that would have allowed U.S.-based insurers to cover health services in Mexico for Texans living within 75 miles of the border. The bill didn't make it out of committee.

Meanwhile, medical tourism worldwide continues to grow. The industry grossed an estimated $60 billion in 2006 and is expected to hit $100 billion by 2012, according to the Confederation of Indian Industry and McKinsey and Co. Generally, people travel to foreign countries for better deals on procedures ranging from breast implant surgery to in vitro fertilization cycles, or for access to experimental surgeries that haven't been approved at home.

There are downsides to getting serious medical treatment abroad—whether it's a face-lift or a knee replacement. Accurate statistics on botched procedures involving foreign nationals at hospitals around the world aren't available, but critics point out in addition to the lack of information about the quality of care in various countries, there are inherent drawbacks in a situation where patients have to return to another country to get follow-up care. And of course there's often a lack of access to malpractice insurance coverage in Mexico and other countries. But a similar argument could be made against American health care, the University of Texas's Warner says: "It's not clear that you have such wonderful protections here, especially if you can't afford to get the care, so then you go to a public facility that's more or less protected from too much malpractice liability."

These concerns aren't stopping Texans who view the hospitals across the border as an affordable alternative. Dorthea says that three of her friends have also gotten medical care in Reynosa, and she'd recommend the hospital to any of her acquaintances. It remains to be seen whether more Americans will take a gamble and bet that Mexican hospitals can provide care that is as good as their counterparts north of the border. Meanwhile, as Warner points out, for the uninsured, Mexico may be the only option.

US teen lives 118 days without heart

An American teen-ager survived for nearly four months without a heart, kept alive by a custom-built artificial blood-pumping device, until she was able to have a heart transplant, doctors in Miami said on Wednesday.

The doctors said they knew of another case in which an adult had been kept alive in Germany for nine months without a heart but said they believed this was the first time a child had survived in this manner for so long.

The patient, D'Zhana Simmons of South Carolina, said the experience of living for so long with a machine pumping her blood was "scary."

"You never knew when it would malfunction," she said, her voice barely above a whisper, at a news conference at the University of Miami/Jackson Memorial Medical Center.

"It was like I was a fake person, like I didn't really exist. I was just here," she said of living without a heart.

Simmons, 14, suffered from dilated cardiomyopathy, a condition in which the patient's heart becomes weakened and enlarged and does not pump blood efficiently.

She had a heart transplant on July 2 at Miami's Holtz Children's Hospital but the new heart failed to function properly and was quickly removed.

Two heart pumps made by Thoratec Corp (THOR.O: Quote, Profile, Research, Stock Buzz) of Pleasanton, California, were implanted to keep her blood flowing while she fought a host of ailments and recovered her strength. Doctors implanted another heart on Oct. 29.

"She essentially lived for 118 days without a heart, with her circulation supported only by the two blood pumps," said Dr. Marco Ricci, the hospital's director of pediatric cardiac surgery. During that time, Simmons was mobile but remained hospitalized.

When an artificial heart is used to sustain a patient, the patient's own heart is usually left in the body, doctors said.

In some cases, adult patients have been kept alive that way for more than a year, they said.

"This, we believe, is the first pediatric patient who has received such a device in this configuration without the heart, and possibly one of the youngest that has ... been bridged to transplantation without her native heart," Ricci said.

Simmons also suffered renal failure and had a kidney transplant the day after the second heart transplant.

Ricci said her prognosis was good. But doctors said there is a 50 percent chance that a heart transplant patient will need a new heart 12 or 13 years after the first surgery.

How old is old enough to decide whether to live or die?

Josie Grove - How old is old enough to decide whether to live or die?
Josie Grove with her baby brother, Charlie, and mother Jacqui, two months before the teenager died Photo: NORTH NEWS AND PICTURES

Jacqui Grove wavered only once. For a fleeting second, she agonised. ''Should we be trying every single thing, anything that might produce a miracle and save Josie's life?'' she asked herself.

Before her on the table sat yet another letter from a well-meaning stranger. In it the author, who had read of Jacqui's daughter's decision to refuse further medical treatment, leave hospital and go home to her family to die, urged her to talk Josie into changing her mind, to try yet one more form of untested alternative medicine.

In that moment Jacqui thought of the pain and suffering her elder child had already endured. Of her quiet resolve, at just 16, to take control of her own life. Should she overrule her?

One quiet comment from her dying daughter banished those thoughts. ''Mum, I just wish people would stop trying to save me,'' Josie told her. ''I know they mean well, I know they are praying for me. But I just want to spend the time left with my family. Build up some memories for me and for you. I want to live before I die.''

Last year, on February 26, Josie Grove slipped into a coma and died with her mother and father beside her. Candles flickered in her bedroom in the family's Northumberland home, her favourite music played softly in the background. Her family told her how much they loved her and how she would remain forever a cherished part of them.

Diagnosed with acute myeloid leukaemia at 14, Josie had two failed bone marrow transplants and countless rounds of agonisingly painful and debilitating treatment. Then, one day, she decided she had had enough. Her cancer was incurable: the consultants had been straight with her. The new treatment they were proposing was unlikely to help. At best it would prolong her life, albeit briefly. But there would be a price. She would spend hours in hospital. They would try to ease her suffering but the treatment would be agonising and her chances of surviving it low.

''Josie thought about it all carefully,'' her mother says. ''For us to force more treatment on her would have been downright cruel, I'm convinced of that. Josie, like all teenagers with incurable cancers, was forced into a very grown-up world much too soon. But she made up her own mind and she never changed it. We respected that right and we will never regret doing so.''

Over the past week, Mrs Grove has been reliving the anguish of her daughter's decision. At just 13, Hannah Jones, from Marden in Hereford, has chosen the same route. She, too, has acute myeloid leukaemia and while a heart transplant could, possibly, save her life, her chances of surviving the operation are slim. She, too, has decided: ''I have had enough. I just want some pain-free time with my family. Then I will die.''

Jacqui Grove knows there are many – just as well-meaning as those who wrote to her while Josie was dying – whose convictions could never allow them to condone Hannah's decision.

''All I can say to them is that my daughter made her own choice about how she would die,'' Jacqui says. ''And, in a way, when she would die. She left this world peacefully, with a host of memories packed into her final months. Memories she could not have created without that small amount of time to live her life as she wished.

''We didn't selfishly agree to Josie's wishes to give us those memories but to give Josie those memories. We are grateful for the memories we have as a result but we wanted to allow her to live like a normal teenage girl, something she couldn't do with all the treatment. That is what Josie wanted. That is what we gave her. I have never regretted that.

"Hannah's parents have also chosen to respect their daughter's wishes. It is a brave decision for them. For us it was the right one. I believe it is the right one for them, too. When I read about Hannah, I thought: 'Just 13, so young.' But I didn't mean too young to make the choice she has, simply that she is so young to have to face this.''

In Britain, the law surrounding such decisions is vague. As an adult, the right to refuse treatment is enshrined in law. For those in their teens the courts can intervene. What is paramount are the child's "best interests".

In Hannah's case, a diligent doctor decided she should be taken from her parents and undergo the transplant operation, regardless of her wishes. To her family's bewilderment their local hospital, Hereford County, applied for a High Court order to remove Hannah from their care on the grounds that they were "preventing her treatment". It was only the last-minute intervention of a child protection officer that has allowed her to stay with her family for the remaining months of her life. The officer had a lengthy talk with Hannah and then persuaded the court that the order should be thrown out.

The moral and ethical issues surrounding a youngster's right to end their treatment have raised questions that have vexed ethicists, doctors, parents and politicians for decades. When, they ponder, is a child old enough to understand and give consent to complex medical treatments? How old is old enough to decide whether to live or die?

Almost all experts agree: age is all but immaterial, it is experience that counts. Priscilla Alderson, professor of childhood studies at the Institution of Education, says her research has found that even young children can give or withhold informed consent to medical procedures. Decisions about treatment, or even whether to live or die, cannot be based on age, she argues.

''Age isn't a helpful criterion,'' she says, ''but experience is.'' Hannah, she believes, is probably better qualified than many adults to come to her own decision. ''Hannah has had ample opportunity with eight years or more of close contact with invasive treatment. It appears that she has thought deeply about the cost of life and the cost of dying with dignity. She sounds remarkably wise. Most of all, she probably knows what it is like to face death.''

Jacqui Groves would agree. Her daughter knew she was dying and understood its finality. Her family used the analogy of the dragonfly to understand life's circle. How its larvae lie underwater gazing at the surface until they finally float to the top to break free as dragonflies. ''But they cannot go back down to tell others how wonderful it is,'' Jacqui explains. ''That is how Josie thought of death. Of course she knew the reality of dying, but that analogy helped her accept her death.''

Just before she died, Josie set up the Josie's Dragonfly charity to raise money to buy arts and crafts for terminally ill children, as well as giving one-off £500 grants in their final
months. In its first year it raised almost £167,000 but badly needs funds to continue its work.

''Josie worked hard with the charity in her last months and she would be so proud of the work it has done,'' says her mother. ''As well as giving money people can buy a range of silver and gold dragonfly jewellery. Five pounds of the cost of each piece goes to the charity. The dragonfly's life span symbolises Josie for us: fragile, free and tragically short.''

Her daughter's decision, she is convinced, was made only after much soul-searching. ''Children like Josie and Hannah are very involved in the details of their treatment,'' she explains. ''The consultants never lie to them. They tell them when a treatment isn't working and what, if any, options there are. They hear things we would prefer to protect children from but they need to hear them. The doctors are honest and realistic so that the child is aware of the seriousness of their condition. And aware of their own mortality. They have to deal with very adult issues.

''Josie certainly knew the reality of death. She had faced the possibility of dying all through her treatment. She knew what her chances were.''

It was after the failure of her second bone marrow treatment that Josie made up her mind. Her doctors told the family there was one treatment left but it would mean another round of painful hospital procedures, and the likelihood of Josie surviving was low.

The Groves took a barge holiday to think things over and, one morning, Josie told her mother: ''I've decided no.'' Her mother gently suggested she give it one more go but Josie was adamant. ''I would be hoping it doesn't work,'' she said. ''I don't want to go through any more.'' Josie never changed her mind and her parents respected her view.

''It isn't easy. In effect, we were letting our beautiful daughter die. But we allowed her to die in the way she wished. She was so very ill after each transplant, she couldn't face it all again. We had seen her in pain so often. It was a brave decision to make and, when she insisted it was what she wanted, I hugged her and told her I didn't blame her at all for making it.

''By the end she really had had enough. Josie knew that those who wanted her to keep trying did so out of hope and compassion. But, as she pointed out, she was the one enduring the treatment, the sickness and the pain. She didn't want to clutch at straws.''

The momentous decision made by Josie and Hannah is more common that we realise, Jacqui believes. ''Time and time again, through the charity, we meet parents who, having watched their child suffer terribly for a long time, say: 'Why don't the doctors just stop?'

''They know the medical profession wants to give their children every opportunity, every chance. But occasionally there comes a time, and these children often know themselves when it is time to say no.''