Welcome to Chasing Life. Look, it's no secret that healthcare in the United States is really expensive. And anyone who's received a bill for a hospital visit recently, a medical procedure, or even their healthcare insurance premium, they know this. The United States spends an estimated $15,000 per person on healthcare in 2024. And at the time, it was twice the average of other rich countries. So it probably won't surprise you to hear that many Americans are traveling abroad. For medical tourism. A few million a year, according to CDC estimates. You've probably seen this on your social media feed.

So I just got back from Turkey from getting a hair transplant, and yes, the swelling is normal, the eye is normal, this is all expected.

I know I'm going to get a BBL out of the country, so I have to do my preoperative work today.

Let's talk about my Mexico dentist experience while I get ready for bed.

For a lot of people, it's obvious, the appeal of medical tourism is all about the cost. It's about the price tag. But cost isn't the only driver, as you're about to hear. My guest today is Harvard Law School Professor Glenn Cohen. He's an expert in bioethics and the law. And he has written a book about medical tourism, or medical travel, as he likes to call it. In today's episode, we're going to learn about medical travel. What questions to ask. And what issues to consider before you might plunk down a huge deposit and start booking those flights. I'm Dr. Sanjay Gupta, CNN's Chief Medical Correspondent, and this is Chasing Life.

Healthcare has always been really expensive in the United States, and I'm a doctor, I work in the system, you know the system well. There's a lot of dissatisfaction with the system in the Unites States. So some of the idea that people would go abroad for procedures, it fundamentally makes sense. I think what is surprising to me a little bit is how much it's growing. Is that because the care is getting better in other countries, or? Is it getting worse here? What do you think's going on?

'So, I think it's a bit of an all of the above situation in that I often tell people, we're a little parochial in the United States that we assume we have the best care in the world, and certainly at our best hospitals we do. But the average healthcare experience of the average American may be just pretty medium rather than excellent. On the flip side, healthcare costs have been going up. The rate of underinsured and uninsured people is down from the peak because of the Affordable Care Act of where it was. So we have people facing more cost pressures. And in general, healthcare has been very inflation-sensitive compared to other kinds of industries as well. So there's a lot of different push and pull factors happening at the same time that I think are motivating people to potentially go abroad.

I want to talk about cost, 'cause as you say, it's one of the primary drivers, not the only driver, but one of the primary drivers as to why someone might seek care overseas. And some of these numbers, this is from a Harvard article about 10 years ago.  Numbers have probably changed since then, but even at the time, it was astounding. Hip replacement in the United States, $75,000. India, $9,000 at the time.  Heart bypass surgery in the United States, $210,000. In Thailand, $12,000. I mean, these are  not incremental differences. These are exponential differences. What are some of the examples of procedures that are thought to be better outside the United States?

So it varies a little bit by country, but I'll give you some examples of things that are sometimes discussed in the literature. So, sex reassignment surgery is an interesting example. Thailand has long been, I think, ahead of us in sex reassignments surgery, and many people think that that's a great place to go for that. India has often been a leading center for cardiac, but the U.S. Is very good at cardiac, too. But when someone's thinking about cardiac, that's the possibility. Dentistry, we don't often think about it as medical. There are many other countries whose dentistry kind of opportunities are better than in the United States and certainly less costly. Now, the problem with dentistry is it's often a longer term sort of thing. So unless you're going to be going back and forth, you're unlikely to want to go for that kind of option. But these are things people do.

And I hear a lot about hair transplants in Turkey. I mean, that seems to be something that's really picked up. I see it all over social media. People are asking me about it all the time. So I have you. What would you say?

Yeah, I might be able to use a little bit of work myself, here. But I will say here that Turkey is well known for the work in hair transplantation. And this is something you probably know as a clinician, that when you want to figure out if someone asks you in the United States, who should I go to for X? One of the things you always ask yourself is how many of the thing have they done, right? The more they do it, the better they're likely to be. And that is one of the the things that the Turkish hair transplant community can boast about is just lots and lots of experience. That is a place where people go. But unlike somebody needing a cardiac bypass, for example, that is a procedure that is elective in all senses of the world. Someone's making a choice, and I don't judge them for the choice. I think looking good and feeling good is an important part of health, but to me it's in a little bit of a different category than somebody whose life and whose health is going to decline seriously if they don't get care soon.

Are there inherent risks going overseas where you're not going to get as good a care as some of the things that you just at baseline get in the United States?

Well, I think you've hit the nail on the head, which is the experience of healthcare in the United States is incredibly variable, right? If you look at the atlas, like the Dartmouth Atlas, or these other kinds of atlases about how care is delivered, you see actually the quality of care and the cost of care very dramatically. There are these amazing studies of subway stops in Boston, where I live, the T, that shows basically how far you go out on a various line and what your life expectancy, how it goes up and goes down. And that's not just healthcare, it's other things too. But healthcare is a big piece of that. So I always ask people, like I think about a good old Joe Biden who said, don't compare me to the almighty, compare me the alternative. And I tell people, think about what the alternative is. What is the quality of care available to you? What could be accessible to you in the United States? And think about what you know about the alternative abroad.

Yeah, that's really interesting. It does place a lot of sort of the focus on the consumer here in terms of them having to do their homework, right? I mean, you do your homework here in the United States, but even with the variability, you do have some expectation, for example, with infection control, that you're probably going to be in a pretty good place. Not all hospitals, obviously, are the same, as you're mentioning. But some of the sort of basic things I think I would worry about in some of these other countries.

Yeah, it depends a little bit on the country. But I tell people that when they're looking abroad, they should look for indicia of quality abroad. And what are the kinds of indicia that it's available to a regular patient rather than a super specialized expert or their doctor? So things I tell you what to look about are the Joint Commission. It has a branch called the Joint Commission International, which basically accredits foreign hospitals. Is this a hospital that's been accredited by the Joint Commission International? It's not exactly the same accreditation as the United States, but it's somewhat similar and that's helpful. Is it the kind of hospital that's formed a partnership with a leading U.S. Hospital, the Mayos, the Hopkins, of the United States? Again, not perfect evidence of quality, but better than much of what's available in terms of quality signals. But I will tell you, even in the United States, we know that patients are terrible choosers of healthcare. And when you see what patients actually respond to, what are the kinds of things they react to, versus what actually predicts their healthcare quality, the two don't line up nearly as much as you would like them to.

You have traveled around the world and I think have been a willing test patient as well in some of these scenarios.

A little bit for pretty minor stuff, but yeah.

Minor stuff. But you were doing that to sort of get a sense of the place and help inform your own reporting and your book and all that I imagined.

Exactly.

What did you learn? Were there surprises?

'There were huge surprises. So first of all, the physical space of a hospital, you have an image of what it's like being in a lot of US hospitals and be very different in different places. When I was in Malaysia, for example, they have different wings for Hindu patients and Muslim patients that look totally different from one another, have different kitchens, different things. In Korea, for examples, there was one hospital I went to where they fused Western and Eastern medicine in that you'd have all of the MRIs and all the machines you'd expect, but actually there was an entire huge room used for brewing tea, and every patient had an individual set of tea brewed for them that was connected to what they did. And then I've been places like that that would surprise me. So like in the Caribbean, for example, where I've been to IVF clinics there and I was surprised they had like a burgeoning IVF practice in a small island where it seemed to me that actually basic healthcare might not be as easy to go to. And then in places like Kenya, for example, were I've seen some of the top-of-the-line machines, for example. But sitting sometimes unused, because actually having the people who are staffed and trained to be able to use them is a problem. So traveling the world is really instructive. It's caused me to decenter my expectations about what healthcare is, but also to be less parochial about the United States being such a leader in this space.

When you say less parochial, you mean it's sort of ingrained into us that the United States is just the leader in these various procedures. You walked away thinking, hey, maybe sometimes that's the case, but not always.

'Exactly. And there are places where they do things differently in a way that actually maybe we can learn something. So one is- surgery is an interesting example. And again, I'm not a surgeon, you are, so I'll defer to you, but one of the things that's interesting is that many steps of the surgery are done in the United States by the same surgeon. Whereas in a place like India, in cardiac, for example, there are some hospitals where I learned that they subspecialize even within steps within the surgery. That somebody closes somebody up, that's all they do. Somebody does just this piece of it, right? And this idea of more of a conveyor belt that I think to us seems a little bit strange. It's like an open question to me whether that might be more efficient but also produce better healthcare outcomes.

You know, I have, just because of the nature of my job, I have operated in countries all over the world. And I have to say, I hadn't heard about the specialization within a procedure sort of thing. That's very interesting. But just the utilization of resources, like something as simple as like, I'm going to count the number of stitches that we use for this operation in the United States versus overseas. And sometimes it can be wildly different. The number of instruments that are used, the length of the operation, the anesthesia. I think that's part of what's driving the cost down in these other places. That might be an example of something that we could actually learn if we want to reduce healthcare costs in the United States.

'Absolutely. Another thing that's interesting is actually the roles, like who does what. So again, we have a very strict division between physician, nurse, for example, and family member. In many of the countries I visited and I've read about and have learned about over the years, actually, family members do a lot more of the post-operative care work that would be done by hospital employees in the United States, right? So this idea- now, they have different family structures, different expectations, different gender relations, too. So I'm not saying easy to transplant over. But it's an interesting difference that sort of caught my eye in terms of the work I've done.

Yeah, I mean, there's always been a focus, I think, on trying to get the patient out of the hospital as quickly as possible. Again, some of these other countries may do a better job of that. Most people, when they're considering something like this, are probably focused on what are the risks here? What are the real risks of having whatever the procedure is done here in the United States versus going overseas? How would you sort of contextualize that? How would you rank order the risks? What are the things you're most worried about when it comes to medical travel?

'Great, okay, so first thing is just to say, especially a surgery, is it going to be done in a way that I'm going to survive and that I am going to flourish? Is it going to done right? So adverse events as part of the process. Second is just infection control, which we've already mentioned. This idea that I don't want to get an infection in the hospital or elsewhere, and whether the travel itself will expose me to infection. Third is the question about follow-up care. Am I sure that I going to be able to transition back to my home country and have someone to take a look for me? And then fourth, and I'm trained as a lawyer too, is just questions about liability. Should something go wrong, am I going to be able to bring a lawsuit and successfully recover or are there going to be insurmountable obstacles? And last, I'll say last on this list, maybe not last in my heart, but last and I think how people think about this, is the effect on the destination country's healthcare access. Am I making things worth by my participation in this trade for people in that country? And what can I do to help people in that country if I have a positive experience?

What about just simple things like language? I mean, you have to be able to communicate with your medical team, your doctor. Is that a problem? Do most of these practices that are taking care of American medical travel patients, do they simply speak English?

'So they often speak English or they'll have licensed translators, right, who have pretty good ability to translate. And this I think is like a first stop that if they're not able to speak the language you're speaking or to translate the medical documents in a way that can be accessible to your home country physician, that's a problem. But another thing I tell people to think about is things like the legal structure about things that don't involve hospitals. So for example, if you are gay or lesbian and you have a same sex partner and God forbid you end up in a coma, do they have the rights to make decision making for you? Are they recognized as such? What are the anti-discrimination laws of the place you're going? If you're an African-American patient going abroad to a place where there's a high amount of antipathy towards people like you, are you going to be protected in the hospital system? Those are things you don't want to deal with when you're critically ill. It should be the last thing on your mind and we want to make sure patients are going to places where they can receive good assurances about that.

We'll have much more of my conversation with law professor Glenn Cohen, plus a checklist of what you should be thinking about if you were planning a little medical tourism. We'll that right after the break.

So, the idea that you might go to a country with the best of interests, you want to get a procedure, you want to do it the right way, but you may be unwittingly contributing to some sort of problem in the local community, stripping resources away from the community, siphoning doctors away, whatever it might be. What can you do about that? Or how would you even know that you may contributing to that problem?

Yeah, so it's a hard problem as an individual and especially an individual who's struggling with a critical illness to say, okay, now you worry about this, but here are the kinds of things I look for more at a policy level, right? What I want to know is what is the ownership structure of the various hospitals, right, how well supported is the public healthcare system? Is there basically a good amount of physicians and an oversupply of physicians in nurses or are they in short supply, and many more of them being diverted towards this new gleaming medical tourism center, and do the people who work at the center, the physicians who work there, are they exclusively at the medical tourism center, or are they spending some of their days in the public health hospital as well? Now that's the kind of thing that me, as a scholar, policymaker, I can look at. As an average patient, very hard for you to find the answer. So one thing I'd like to push is that the kind of accreditors we have, like the Joint Commission, that they take this as part of their mantle too, to not only evaluate the quality of the healthcare and the quality of the procedures at a hospital system, but whether it's operating in a way that is ethical in regard to the entire healthcare system of the countries in which they're located. I would love for patients to have an easy way to access that information, like fair trade coffee, the same thing for fair trade medical tourism.

But right now that's hard to get.

Right now, it's very hard to get.

Let's talk about stem cells for a second, because this is another area where I have friends of mine and people that I know who have traveled overseas for stem cell injections. And these are discerning individuals, right? These are people who do their homework. They are usually people who have money, enough money to actually travel and do this sort of thing. And yet, part of the reason they're doing it is because they can't get those same stem cell treatments here in the United States. So, this is less an issue of cost. And more a question of accessibility and availability. What is your top line thought on that?

'You know, my top line thought is to ask, why is this not available in the United States? Sometimes the answer can be a regulatory hassle that's not worth it for a small company to enter. Again, I don't want to make it sound like the U.S. FDA process is the best possible process in the entire universe, and it gets everything exactly right. But what I've often found is the sellers of stem cell therapies often are not sharing their data in a widely available way. They're not subjecting what they do to peer-reviewed kind of review. And that just sets my antenna up is to say, if the main thing you can tell me is somebody got this and they felt really great afterwards and they wrote a great patient testimonial or your friend who played professional sports had this and then have one of the best seasons. That's helpful information, but it's not the kind of data that I think we should be basing these sorts of decisions on.

Before you would even consider medical travel, okay, like, not the checklist after you've decided, but even before you ever think about medical travel, are there some questions you should be asking yourself? Like how would you think about it?

'What is the lowest cost where I could access this in the United States in a reputable place that I have trust in? Because I don't think I should be thinking about going abroad if it's a cost reason, unless I'm assured that I'm not going to be able to get it in a timely way in the United States, that's the first question. Then as I'm starting to think abroad, am I healthy enough to actually travel? If I'm chronically ill, is this flight- what's that going to be like? Am I going to catch an infection along the way? Then I'm in the place now where I'm trying to think about what kinds of places I might think about going. And I guess I want to be honest with myself about how much sophistication I have and how much help I need and whether I ought to be thinking about relying on someone else to help me make this decision. You know, it would be wonderful was if my own doctor that I could work with him or her. But realistically, I think most doctors, if you came to them and asked them this question about going abroad, they'd say, I have no idea and I don't think you should do it. So thinking about whether to use a facilitator or to be part of a patient program at one of these large hospitals. And then now we're getting in the place where I've decided to go abroad and we can talk about what the choices ought to be there and what I should look for. But those would be the first steps I would think about.

Going back to this thing again, as doctors, we get asked these questions, and I think most doctors here, some are inherently suspicious of patients going overseas. I think that exists, but for others, they just don't know. They just don't have the data. They don't have anything to sort of sink their teeth into in terms of making a good recommendation. So it seems in those cases, finding one of these medical facilitators or somebody like that is probably the right thing to do.

Exactly, and our doctors are overworked and they have so little time with patients already that the idea that they're going to be able to help you in this small window of time you have with your physician, unlikely to be successful.

All right, so how do you find a medical facilitator?

So I start by looking to see about accreditation, right? So I either look at facilities or I look at facilitators and I look what their accreditation is.

Just on Google? You just on Google, you just Google this or, where do you find them?

You can start by Googling it. It's not a bad place to look. There are some books out there, sort of a yellow pages of facilitators. The Medical Tourism Association is one of the big associations in the United States. Now it's a big tent, so I'm not going to say the fact that someone's gone through one of those certification processes is automatically a gold star to their name. But I think it's helpful place to start to look to see who's been certified or accredited or listed by them. And in terms of facilities, I look at the facilities that see the most American patients, that are Joint Commission International accredited, and that are partnered, if possible, with a U.S. hospital. These are, I think, easy cuts in the data, and I try to narrow down my search that way.

You know, I've got to tell you, it's hard, like even to get transparent information in the United States, if someone wanted to figure out how many procedures a particular surgeon does, maybe you can find that data. A lot of times the way it's presented is in terms of outcomes, you know, here's how my patients do, not necessarily the number of procedures that are done. How easy is it to get that sort of information overseas?

So some of the hospitals, because they're in this market to try to sell their services to you, I think, are more willing to share that information. But I warn people these report cards, even in the United States, like we had this experience, this history, a couple of states introduced cardiac report cards and it led to all sorts of game playing where certain hospitals started declining the patients that are less likely to succeed as a result. So there's all sorts of way where the data generation could be gained in such a way that you should be treated with a very heavy grain of salt.

Yeah, it is really interesting because some of the hospitals that take care of the sickest patients, and these are typically tertiary care hospitals, big academic centers, if you look at their outcomes numbers, just period, they're not probably going to look as good as a community hospital that's taking care of patients who are less sick. It's this paradox, and I think most people sort of fundamentally understand this, and they still want to go to a big academic center if they're really sick. But if you just look at data, It's tough to decipher, and I imagine even more so overseas.

Absolutely, because you don't even know what the denominator is overseas. You don't know the incidence of the disease. There's all sorts of information that might be different from the United States.

So the medical facilitator can help with that. And I imagine some of that is based on their own experience from patients that have gone to these centers, what their experience has been like, their word of mouth, and then sort of bringing that to a potential new patient.

But here's a caution, figure out how they're getting paid. Because there is a practice, there has been a practice of referral fees where the facilitator gets paid by sending someone to a particular hospital. If that's the case, you don't want to work with that kind of person. It may cost you a little bit more, it may cost a little more to pay for a facilitator who's not getting a referral fee, but you want to make sure you understand that they're making a judgment that's aligned with your interests, not necessarily aligned with the places they're going to.

Look, I think part of the reason we're having this discussion is because this might be the right decision for people who are thinking about going overseas for medical travel, but you need to do your homework. And when we say that, there are specific things that you should be doing to do that homework. These are really specific questions, some of which are getting at here. The checklist, what are my personal circumstances? How much do I need this procedure? How quickly does it need to happen? How healthy am I? Can I tolerate the travel? Like you said, that seems to be sort of near the top of the list. Second of all, who's taking care of me, right? I mean, you're probably going to need someone to care for you, especially if they're going to discharge you from the hospital in whatever foreign country you might be in pretty quickly, which is something that often happens, as you say. How experienced are they getting the data on the experience of the team? The operative team, the surgical team, but also the anesthesia team, the nursing team, all of that really important. And then I think, finally, let's say something goes wrong. Paint a picture for me of what happens when something goes wrong. Those are sort of the main things, I think that you talk about on your checklist.

'Exactly. And I think in terms of what goes wrong, you know, what goes wrong if I get sick and I get stuck there? Do I have a loved one who can come? What's the legal system? What the chain of authority for getting me out? What is the follow-up care? What happens when something goes wrong when I come home? Is there somebody willing to care for me at home? And then again, what are my legal options if I have to bring a lawsuit because there's been an adverse event? Can I actually even sue a foreign facility in the United States? Or do I have to go abroad to sue them? And what kind of law protects me? Those kinds of things.

Is there an agreement that that one signs with a foreign or an overseas hospital before they go over there? And if there is is that something that a lawyer should be involved with?

I think if you're asked to sign a contract and there ought to be some contract and some agreements, you should have a close look and if there's legalese there you don't understand, you should definitely have a lawyer or someone trained in law take a look at it. Because again, you don't want to have waived away a whole bunch of your rights. Even though, truthfully speaking, if you are injured abroad and you try to sue from the United States, it's not the easiest lawsuit to bring. So I don't think people should expect that even if they don't sign these agreements, they're going to be in a great position. But you want to make sure you haven't signed away your rights."

So what do you tell people then? What do you, I mean, you're the guy. Like if I were, somebody were to come to me right now and ask me, I'd say, you know what? Call this guy, he's written a book about it. He's the expert. He's been thinking about it for a decade. What do tell people?

I tell people, how important is this for you? If it turns out your life depends upon it and you don't have a good option in the United States, it's a very strong reason to think about it. If it turns out, well, you'd like to go on a vacation and get this done and you could pay for the vacation, less compelling story and unless you have a lot of compelling data pushing you to say it's safe and it's going to be effective, I think it's reason to be very skeptical about doing it.

I don't mean to keep coming back to this point, but again, you're the expert. And by the way, you know, I'm lucky to have my hair still. I don't think I'm going to need a hair transplant anytime soon. I think your hair is fine, but you did sort of point to it earlier. Would you, again, that same question, right now, okay, you've gotten to the point, you look in the mirror one day and you're thinking, you know what? A hair transplant may be in the future. Would you go to Turkey or a country like that to get a hair transplant?

Great, let me walk you through my decision making on this. First thing is I get two or three estimates in the United States, including different parts of the United States to figure out what it would cost me because this is something I'm going to pay out of pocket.

You'd rather be in the United States, still?

I just start by looking at what that number looks like, right? I have a strong presumption that if I don't have to go abroad and go under the knife somewhere else and have to recover there, even if the quality is very good in Turkey, I would just as soon rather be here at home to start with. Then I'd compare and I'd say, how much money am I saving? And then I'd try to figure out whether the risk differential for me, the pain, the fact of having to probably bring somebody with me and coordinate all of that, is it worth it and how important is this for me? Would I rather wait a year or two and save up more money for the U.S. version or would I rather go now? And if it turns out it is $100,000, then it looks like much more difficult for me to think that I'll ever be in a position to have saved up the money to make up that difference. But if it turns out it's a couple of thousand dollars here or there, I just ask myself, how sure am I about the quality I'm going to get abroad? And then if I've decided to look at it, I'm going to basically talk to as many people I can, including doctors here in the United States, that do this kind of work and say, who do you respect? Who do you know? How would you select a facility if you were recommending a patient? And as you say, most doctors are going to look at me like I'm crazy or not going to say, I don't know. But the hope is that I could get guidance from somebody who's a true expert in the field because I don't know enough about hair transplantation to be able to say that this method or that method is the better way to do it.

Well, maybe that's a good place to leave it. I appreciate that. It's given me a lot to think about.

It's great to talk with you as always. Thanks for having me, Sanjay.

That was Harvard Law Professor and author Glenn Cohen. I 've got to say, I found the conversation with him really fascinating. Gave me a much better understanding of just how complicated medical tourism can be. I really learned a lot. Hope you did, too.