Interview with Stephanie Sulger from Medical Tours International (transcript)

David Williams: This is David Williams, CEO of MedTripInfo.com. I spoke earlier today with Stephanie Sulger. She founded Medical Tours International back in 2002. Stephanie and many of her colleagues at MTI are nurses, and she told me about how she's translated her nursing perspective into how MTI cares for its customers.

I also spoke to her about quality control, travel friendly doctors in the US, and several other topics. Listen in and hear what she has to say.

Stephanie thanks for joining me this morning.

Stephanie Sulger: You're welcome. I'm pleased to be here.

David: Stephanie, you are often called one of the pioneers in the medical travel business. Can you tell me how you got started?

Stephanie: Actually, when I look back, I really started this when I was in nursing school. One of the things that nurses do, in the United States, and this is classic, this goes back to Florence Nightingale, is that we protect patients from the environment. We protect them from microbes, germs, anything that could harm them. More and more we protect from the technology that we're using around them. We protect them from stress. We try to educate them and so forth.

So, when I first went overseas and I went to a doctor that I had actually worked with, in the operating room in New York, I met an awful lot of other patients and I was really surprised. This was six years ago, and I thought how are these people choosing doctors? How do they know where to go? And they would tell me that their aunt had told them this one was good, or that one was good.

Some of the patients that I met were not happy with what happened, and some were very happy. And I began to realize that we hadn't really educated the American public well enough to make really, really good choices about health care.

David: When you were founding Medical Tours International, what sort of services did you start off with? What kind of need did you see and has that changed over time, since you founded the company?

Stephanie: We were focusing mostly on who they were going to and reducing their stress. Those were my two main things, because that's what I saw first as a need. It has changed since then. It's developed into a much higher, much more evolved system of sending patients than it was initially, where we would just say, "OK, this doctor looks like it's a good destination," and we've given the patient enough information, so we've reduced their uncertainty and stress to a certain point. It's gone beyond that now.

David: And the patients, who are coming to you, are they more prepared? Do they know more what they want or is it just a broader array of patients who would consider going abroad, in the first place?

Stephanie: Well, now it depends on the country, basically. If you take a smaller country, like Costa Rica, word gets around pretty quickly. Patients pass information around more quickly than they would, for instance, for one of the larger Asian countries, where people are still really more fumbling in the dark than they would in a smaller country. So, people are a little more knowledgeable.

David: And what do you find, in terms of the kinds of procedures, that people are going for? Is it the same things that it has been or are there additional kinds of procedures that have come online, that patients consider, over the past few years?

Stephanie: Well, historically, I think the focus has been plastic/cosmetic surgery and dentistry. I think that the shift is happening towards more surgeries that are considered even more necessary than those specialties, than the specialties of cosmetic surgeries. So, we're seeing more ortho, neuro, prostate surgery, stem cell transplants, also just general surgeries. We've sent hysterectomies, hernias, that kind of thing.

David: Now, have you had to expand the locations that you're sending people to in order to cover those additional procedures? Or can they be handled in the same countries, or even by some of the same physicians that you were working with originally?

Stephanie: We've expanded actually, on both ends again. We're driven by what patients are asking us for, but that's not the primary thing, although this industry, "Medical Tourism," as they call it, is being pushed by consumers.

But, a vacuum is created because of the way we've developed the company and the safety features that we have. We're contacted by overseas facilities to come and actually look at them and help them become American-friendly and more comfortable for American patients, have a look at them and see if the features that they're offering; how close do they come to what we're used to working with in the United States' hospitals.

David: So, would it be almost a kind of a customer service accreditation, or training for them?

Stephanie: Yeah, that's a good way of putting it. We've been through many accreditation processes here in the United States. We've dealt with so many safety issues; we've seen so many medical errors, which is why we have so many quality control standards here in the States, and higher costs.

So, overseas did not have the advantage of having reportable medical errors, and therefore putting quality controls in place. So what we do is bring that with us and we say to them, "You don't have to repeat these mistakes. They're going to happen because they happen to us; they're more likely to happen to you, because of the language and the distance and everything else. So here, do this now, before you have a problem."

David: Now, what sort of fees to do you charge? How do you make money for MTI, given all these services that you're providing?

Stephanie: Well, we're paid by the hospitals and the doctors. We are basically paid retainers by the doctors and hospitals to actually set them up. We don't take everybody who asks us to refer patients to them. We're really selective. If they do, then we charge them because we have to verify their credentials, we have to keep a database of all their information, we have to keep their credentials up to date. There is a lot of work involved in setting a doctor or hospital up.

David: Once you've done the initial research and a physician or hospital is set up and you start sending patients there, do you get feedback on those specific providers in order to be able to help them improve and to revise your network over time?

Stephanie: Yes. There are two aspects to that. One of course is, we ask the patients to fill out evaluation forms and that's always immensely helpful in terms of what the experience was from the patient's view, where were the gaps, what were the good things, what were the bad things.

The second part of it is really - we're developing this more and more. This is something American medicine really, really needs to step up to bat to. The only way that we can measure the quality of overseas care is to have doctors in the US see patients when they return here.

That part of the evaluation, the clinical part of the evaluation, is really, really important. So, what we've done is, we currently have 800+ physicians in the United States that we call "travel-friendly" doctors. We ask them to follow up on these patients. See them when they return to provide care to them, whatever it is that they need and to keep track of infections, complications, dislocated hips, anything that happens.

David: Now when you talk about travel-friendly physicians, can you tell me a little bit about what that term means and how you find such people?

Stephanie: Well, I started out finding travel-friendly physicians because I was still working in the operating rooms when I started doing this work in 2002. So I would just grab the surgeons I was working with and tell them, "I have patients coming back. If I have one in this area, I want to send them to you," and that's how I started it. And I said, "You're going to go tell your associates and colleagues about this and they're going to see patients too," and they've all agreed to it. Everybody I've asked has agreed to it.

So it spread from there so the patients will contact us with their doctor's information. That's part of what we, the data that we get from them, and we contact their doctor and we ask him, "Will you see the patient when they come back to the United States?" I think if it's explained well, if it's explained in a way that they understand that these patients are not waiting for American medicine to give them permission to go overseas. They're going whether we like it or not. Whether we think it's a good idea or not, they're going.

So I tell these doctors basically, "This is the way to practice medicine now. This is something you're going to have to look at for the future." Most of them are fine with that. Actually I can't remember a doctor ever saying no since I started doing it. Maybe the last 30 doctors that I've spoken to have either offered to reduce their prices here in the United States and have me refer patients to them, or I've actually been contacted by medical practices here in the United States to refer patients to them at a reduced cost. And now we have imaging centers that will do our imaging for discounts for international patients.

David: So they actually see a place for themselves in the chain as opposed to seeing overseas providers being competitive with them.

Stephanie: It has to be explained to them correctly.

David: Have you gone so far as to see physicians in the US who will actually refer patients to you or refer them overseas for care?

Stephanie: Yes. We have a couple of different groups. We've had several doctors do that although they prefer to stay - there's a lot of paranoia about this. There's a lot of paranoia with patients about this. Patients don't want insurance companies finding out they went overseas. Doctors don't want insurance companies or other entities finding out that they have anything to do with working overseas. But yes, we do have that. We have also overseas hospitals that refer, whenever they get a contact from a US patient, they'll refer them to us to process.

David: So tell me a little bit more about insurance more broadly. What's the state of play in the insurance industry in terms of coverage for patients who go abroad for care? Can a patient get coverage? Can they get reimbursed for trips that they take overseas?

Stephanie: Well, not really. Not right now. There are movements in that direction. It's very slow.

David: You talked about steps that you're taking as a company to monitor quality of various overseas providers. Are there things that the medical travel industry overall is doing to have consistent quality levels or any kinds of programs to promote higher quality?

Stephanie: Well, there are, there's two layers of action or inaction, I would say, going in. There are medical tourism companies and here again we're dealing with people who generally don't have a medical background. They may have worked in administration. Some of them have never worked in healthcare and so when they say things like, "This is a top hospital" or "This is a leading hospital" or "This doctor is credentialed here" they really don't know what that entails. They don't know the incredible complexities and issues involved with measuring quality and measuring outcomes.

And then putting interventions in place and measuring those qualities and outcomes, which is expensive. Which is part of the reason why healthcare costs so much.

But that said, at least the work's been done. But if you haven't worked in the industry, you don't know those things. You really don't know what a good hospital looks like. You can walk in and say, "Well, there's a Starbucks in the lobby. It must be a top hospital." But are their monitors calibrated? Those kinds of things. What percentage of the people have had US training? Is the hospital re-sterilizing disposable equipment, which is something we found at one of the hospitals that we had started to refer patients to when we looked into it more deeply. Are the devices actually FDA approved or are they knockoffs from China? How does anybody that doesn't have a medical background do this kind of research? That's what worries me.

David: Well, can you tell me what sort of recourse does a patient have overseas if something goes wrong? And certainly things will go wrong. They go wrong in the US. They're going to go wrong anywhere. But what kind of recourse does somebody have compared to what their options might be if they were in the States?

Stephanie: Well, we tell them up front it's different. You can sue a doctor overseas but then again you're going to end up in an overseas court and there are problems there. It takes a long time. India is putting something in place actually that will address this issue. They're working on it as a country. There are hospitals in Portugal that actually have medical tourism insurance where if you develop a complication, it's covered. The government requires that those hospitals have it, carry that kind of insurance for all patients, including international.

David: And would that cover a patient once they return to the US or would that be in Portugal?

Stephanie: No. It's actually their care there which of course is a problem because patients come back here and that's generally when the problems will happen, although they can happen overseas. We track complications. We had two out of 3,000 patients, we had two very serious complications and you can directly relate those to non-compliance. And typically in the United States we're an adventuresome group of citizens. I mean, we travel long distances to get here. We're multi-cultured. We're risk-takers and the people that are going overseas have that edge to them maybe in a bigger way.

So we tell people, "Follow the directions. Do what we say. Stay in the country as long as we tell you to stay. Don't go bungee jumping, whatever." I'm exaggerating.

David: Right.

Stephanie: Don't do anything risky. I mean, look what you've gone through to get here. So we really focus on that. We try to choose patients at a good time of their life. When they contact us we didn't take a patient that went through Hurricane Katrina. There are many things that you can do to decrease complications. There's a good time in your life to have those surgeries and you want to choose those well. Be well prepared for it. Decrease your stress, decrease your uncertainty, be fully informed and walk into the situation knowing that you can walk away at any point.

David: But how should a patient assess if they actually are a good candidate for medical travel? It sounds as though if they were to contact your company you'd help them through the process of determining if it's a good time in their life, if they're doing something appropriate. But, just in general, if someone wants to figure out, "Hey, should I go abroad for medical care?" What are the kinds of questions they should be asking of themselves?

Stephanie: Basically it depends on how good the person is at looking at their motives honestly. We don't feel that right now it's a decision that people should be making on their own. A small country, cosmetic surgery, lots of information out there, yeah. But the rest of it there's not a lot of information out there that's factual.

We're very concerned about people who decide this on their own. Are people - no, I don't think when you put people in a situation right now, and I'm not saying that people aren't smart; I think they're really smart. But I think that they're smart given the correct information with medicine. I think a little bit of knowledge is an extremely dangerous thing in medicine.

So people that - what are they measuring? I don't think we educate them well enough here in the United States. I think we've failed in educating people about what real health is, about what making good choices is. I think that that's glossed over by business, managed care, insurance companies, ads on TV for medications where people were then driven to doctors to choose medications based on ads they had seen on TV.

So have we, has medicine really stood up, taken it in their hands and educated people? I don't think so. Not in my career. I feel like I failed there. So now we've got a group of people who are going, "Oh wow, I can go anywhere in the world," and how are they going to decide if they're well enough to go? Do they know that altitude actually affects them? If they stay at 4,000 feet two days pre-op? Or if they're in a dehumidified cabin of an airplane where their oxygen saturation drops to 92? I mean, how do they know these things? Do they know that they are at higher risk if they've never had a general anesthetic? I don't think so.

David: Now what about this term "medical tourism?" At first blush, those don't sound like two words that go together. Is that a term that you like? I know that everyone uses it.

Stephanie: Right. Everyone uses it. Kind of exotic and sexy and people seem to have grasped it on some level. My fear is that the tourism part dilutes the medical part and makes people kind of, their eyes glaze over. They see themselves on a sunny beach being fed margaritas before they see themselves in an operating room hooked up to an IV. Not that I want to make things real dour. I am kind of the party pooper of medical tourism. As long as people understand that the medical part comes first and is the biggest part of it and they're educated properly... let it live. Whatever they're going to call it.

David: We're about to have the release of the move "Sicko" which I'm sure is going to have an impact on the healthcare debate in the US. It's already happening before the movie's out. Do you think it's going to have an impact on the discussion about medical travel or medical tourism as well?

Stephanie: First of all I just have to say this, and I'm not sure quite how to say this about Michael Moore. But he is between 80 and 100 pounds overweight. And here he is, educating the public about healthcare. Now maybe that's what we need, I don't know. A character like that to educate us, maybe that's what it takes.

But "Sicko" doesn't tell us anything that we didn't know about the healthcare industry here in the States about insurance, pharmaceutical companies, lobbyists, everything. I think that most people knew there was something very, very wrong, that it gained a lot of momentum while we were taking care of patients. And I think the patients are somewhat aware of that as well. Will it have an impact on medical travel?

He went to Cuba that we can't even use right now and the healthcare there is not the kind that American patients are looking for at this point either. So it could have an expanding effect in terms of, "Wow, I could go to another country," and it could also have a negative effect in terms of Cuba. How do I get to Cuba?
David: Right.

Stephanie: So it's a piece of journalism. It's getting an awful lot of hype. The problem is they're all talking about universal healthcare. So here we are looking at a situation where we've got to. In the 1960s and 1970s - taking care of patients - it was pretty much we would tell them to show up, we would take care of them and don't ask any questions, including, don't even ask what your blood pressure is because we're not going to tell you.

So now were going back to that's the kind of situation again, where we're supposedly going to come up with a system that takes care of everyone. And offering that to the American public in a state of need is like offering candy to a kid that's a diabetic. They're going to look at it and go, "Yeah, yeah. I can have that? It's not going to hurt me?" Well, I think it's a bigger chunk than we can bite off. I think that universal healthcare perhaps is not the answer. Michael Moore is a good example of somebody who wants to show up and be taken care of. And a lot of us are like that. Just help me. I don't know what to do.

David: Can you see a possibility of having a primary care physician relationship overseas? Most of what we've been talking about has been procedures or in some cases treatment, but would it be feasible to actually have a primary care physician overseas with the modern technology?

Stephanie: Yes, we actually have patients that have that already. We have a patient for instance that went for a couple of different surgeries. One of them was orthopedic and then he had to have, he was actually having neurosurgery procedure and now he hops on a plane and goes to see his primary care physician overseas. He changed jobs. COBRA for his new organization was too high for him and his people so he opted to just grow his new company, not use the money for insurance, became ill, and had to go overseas and ended up just being so happy with the attention and the care and the hospitality he received.

There are other patients, cardiac patients, who now will go overseas for their cardiac checkups. People are going for angiograms and they have a primary care physician that they see overseas before they have the angiogram and they end up going back to him or her for their annual checkups.

David: I've been speaking today with Stephanie Sulger from Medical Tours International. Stephanie, thank you very much for joining me today.

Stephanie: You're so welcome.