So much is being written about the booming business of medical tourism now. When you read all the online testimonials you get the impression of international hospitals that are more like five star resorts. There are plenty of guidelines and resources for selecting your doctor if you decide to go overseas for medical treatment. Be sure to focus on that aspect – the doctor – and don’t become enthralled with the fancy decor and gourmet restaurants dotting the lobbies of the famous medical tourist centers.

That subject – focus on the doctor and not just the hospital – has been a common theme in a number of recent accounts of health care received by patients at Thai private hospitals. It is hard to say if there is a trend developing but it wouldn’t be unexpected as the industry experiences rapid growth. Those wonderful hospitals have some very busy doctors and some patients are complaining of rushed consultations and sometimes even questionable recommendations regarding treatments.

Even when someone has been a long time patient of their favorite hospital they sometimes end up being surprised in an unpleasant way. There is a recent story about Mission Hospital in Bangkok that is a good example. The patient in that case had been using Mission Hospital exclusive for some time and had always been very happy with the care and service. But then he happened upon a doctor who seemed rather callous in his remarks and not very attentive to the details of the case. That story ends up with the patient complaining to several departments and telling them that “This is the only hospital I ever go to and I can’t see myself going anywhere else.”

That may not be the best approach to take. Patients should keep in mind that many doctors in Thailand practice at more than one hospital. Many others actually have their own clinics and use the hospitals’ facilities when they need to perform surgeries or complex procedures. So the advice is to find the best doctor and make that choice first, then choose the hospital. This may even lead you to try a public hospital because some doctors practice at both public and private hospitals in Thailand. That may seem a little unusual or even undesirable given the usual impression of public hospitals around the world. But some of them are excellent, although certainly not glitzy and they are adapted more for the locals’ tastes and not international tastes. Typically, if you see a doctor first in a public hospital he won’t suggest seeing you at a private hospital, and he will point out that you will get the same treatment just at several times the cost. The reverse is probably also true, that he would not recommend you visit him at a public hospital if you first saw him at a private hospital.

The health care reform law has come and gone, at least the part leading up to the passage of the Patient Protection and Affordable Care Act. Plenty of discussion and legal challenges will continue into the distant future. Some of that banter will revolve around the moral hazard created by the new rules, something that should have been clear to the legislators behind it.

The term “moral hazard” should be well known to everyone who has studied finance. It is discussed in many college courses to some extent when studying financial instruments such as insurance. One of the clearest examples of creating a moral hazard is fire insurance. A policy that would pay greater than the worth of a home under any event would create an incentive to torch the structure for gain, hence creating a moral hazard. Another example would be a very large life insurance policy that would pay out regardless of cause of death, creating an reason for a bankrupt and depressed person to commit suicide in order for their family to receive a substantial insurance settlement. Insurance issuers try to reduce such risks by placing restrictions on benefit levels and disqualifying certain events from coverage. Suicide, for example, almost always results in no benefit is paid.

It would appear that the moral hazards introduced by the new health care reform law weren’t thought about or addressed in advance. For one, the rule that all in the U.S. purchase health insurance or face a penalty creates a moral hazard for everyone who examines the relative costs. Available ]research papers|studies] show that in 2009 the average cost of insurance coverate was about $4,600. That is the “average” person would be paying nearly $400 per month in insurance payments. Due to the new law the penalty for not subscribing to health insurance can be as high as $695, substantially lower than the expense of buying insurance. But the cost disparity between paying for coverage versus simply paying the penalty isn’t the key enabler of the moral hazard. The key is that the new law forbids insurance companies from refusing benefits to persons with pre-existing conditions. So there is no risk that people would be unable to obtain coverage if they became ill or injured. Considered together with the cheaper cost of going uninsured there is a large loop hole that causes a moral hazard that will certainly be exploited by some people.The tactic is simple. Don’t sign up for health coverage. Settle for the fine each year and save nearly $4,000 in savings. If you become sick or hurt then buy insurance to take care of treatment costs – you can’t be denied. With this strategy you can buy the most expensive and highest coverage insurance to pay for most of your doctor when you need it.

Time will tell if this moral hazard is reduced before the new legislation becomes effective. Without some mitigation changes one would expect insurance premiums to increase as people choose fine over coverage and fewer people buy insurance. That will make more people to take advantage of the situation again raising premiums, with the whole system growing out of control.

When you go to a hospital for treatment in the U.S. do you research the hospital’s certifications? Or do you just assume it is certified and passes all the requirements that any first world hospital should, and what are those anyway?

But then you think you might want to beat the cost of state-side treatment by exploring medical tourism, and suddenly there are all sorts of concerns are qualifications, certifications, etc. You know, your local hospital may be substandard compared to an overseas hospital, yet you don’t even think about it.

Nevertheless, if you are planning to travel to a foreign medical facility you probably want to check if it is JCI certified – that’s the international hospital certification body. FYI, here is a list of Thailand JCI certified medical centers. Those JCI certified hospitals are certainly high quality. The little bit of unpleasantness about them is that they are almost always “international” hospitals that are “westernized” to suit westerners tastes which means that they have fancy lobbies, restaurants, and lovely in-patient rooms. And they cost a lot more than non-westernized hospitals that provide equal or better care to locals at lower prices.

There’s nothing wrong with that if you like paying more for luxury. It’s just that you shouldn’t discount other hospitals because they aren’t JCI certified. Take for example Siriraj Hospital in Bangkok, the oldest hospital in Thailand, and the hospital where the King of Thailand is treated. You must consider for a moment that the King of Thailand is one of the richest men in the world and can afford treatment anywhere. If he or his staff thought that better treatment was available at one of the JCI certified hospitals you can be certain he would go there, but he didn’t. Siriraj Hospital is not JCI certified but is considered one of the best hospitals in Thailand.

Or maybe it will be the next bubble, because that is, after all, the engine of the American economy, bubble growth followed by bubble burst followed by the next bubble. So it may be quite appropriate to compare the “wellness” industry with the dotcom boom of the ’90s. That is the comparison made by speakers at a recent conference that was covered in the New York Times (article here). They called it a “a health innovation and investment conference” and the focus was on the business opportunities emerging in health care.

Another comparison was made to the new “green” economy, which is perhaps unfortunate because that has largely be hype so far. Instead of investing in “going green” there is talk of more offshore drilling even in the face of what may turn out to be the largest man made environmental disaster ever, the one caused by the oil leak in the Gulf of Mexico. But if the hype can be peeled away the point about it becoming a much larger issue in the minds of most Americans is true.

At the conference Dr. David M. Lawrence, former chief executive of Kaiser Permanente, floats some interesting numbers. 95 percent of health care spending is spent on “sick-care” he says. The trend needs to move more of those resources to “health-care”, i.e. keeping people healthy rather than waiting for them to waddle into the hospital enormously overweight with diabetes and a host of other lifestyle illnesses. And he asserts there are significant business opportunities in this shift.

I wonder, because so far all I see are more lame attempts to cap costs for sick care rather than tough love to force people to live healthier lifestyles. There seems to be no effort to strongly correlate unhealthy lifestyle and higher insurance premiums. Overweight smokers should not be paying the same for health care as thin non-smokers. That is so obvious but it doesn’t buy votes so we probably won’t see that being addressed anytime soon.

Regardless, folks in the business are pushing the idea and have written some books with great titles like “The Innovator’s Prescription: A Disruptive Solution for Health Care.” Yes, we like “disruption” of existing markets by “innovators” so it’s got the right buzzwords. Is there substance to it, that’s the question. Actually, one of the key the ingredients for disruptive health care solutions is the internet itself. A good example is Watermark Medical which offers an at-home device for monitoring sleep apnea and a web-based service for the diagnoses. If you know anyone who has ever had sleep apnea tests done it is thoroughly inconvenient, requiring you to go to a special facility and spend the night there wired up to instruments. It’s a wonder the tests are of any use at all since for most people getting any sleep at all is next to impossible. The home solution would be much more convenient and certainly lower cost than using a special facility.

The sleep apnea gadget sounds interesting but that’s a small example of disruption of a tiny spot in the overall health care industry. There must be much larger areas that innovators will attack. Online medical records must be one of them, and that will face great resistance from many sides, as well as attempts to sell enormously expensive and cumbersome software systems for implementation. Can’t wait to see the SAP of medical records bog down the entire process.

Patients traveling abroad to seek treatment that is not covered by insurance or simply not available in their own country is nothing new. But how about doctors traveling abroad to perform those treatments? Perhaps that has been going on for a while as well, but it just got a lot more formalized and organized.

A medical tourism company called Global Medical Excellence based in California has come up with a service in which they arrange for U.S. doctors to perform surgery at international medical centers. The company has entered into contracts with U.S. Board Certified surgeons who agree to travel to India or Lebanon (and soon other countries) to perform surgeries on GME’s patients. They expect to have 400 doctors signed on by the end of June.

The idea is compelling in that many potential medical tourists have concerns about foreign doctors performing major surgery on them. Despite the fact that those doctors may have the same or even superior training and skills as domestic doctors, many patients just aren’t comfortable with selecting a doctor on the internet. That concern could be eliminated with this service.

GME is claiming that patients will save 70% to 75% on the cost compared to the same surgery performed in the U.S. That is similar to the savings achieved with foreign doctors so it is clear that the cost savings isn’t about doctor fees but about all the overhead of medical practice in the U.S. A major component of that is the cost of malpractice insurance due to litigious patients being awarded enormous judgments for emotional suffering, something that is not practiced in many other countries. An open question is what exposure do doctors have once them return to the U.S. after performing surgery overseas.

A report coming out tomorrow will recommend that the government intervene to put limits on the amount of sodium in food, and the FDA will act on that advice, the Washington Post reports. Citing anonymous FDA sources, the paper says the agency is aiming to work with manufacturers on a step-down approach, in which salt would be subtracted in small increments over a decade. The hope is that the phase-out will be unnoticeable to consumers. The limits aren't yet decided, and it's not yet known whether inherently salty foods, like pickles, will get an exemption. Such a reduction will be recommended by the Institute of Medicine, which Wednesday will release a report that says merely encouraging manufacturers to cut salt hasn?t succeeded in curbing U.S. daily sodium consumption, now about twice what the government says it should be, according to the WP. Salt is linked to high blood pressure, a risk factor for heart disease. But as the WSJ reported earlier this year, some food makers have already ratcheted down the salt added to packaged foods which is where most of the sodium in a typical American?s diet comes from. ConAgra and Campbell Soup have been doing so quietly, since products with drastically reduced sodium content, and labeled as such, aren't always appealing to consumers. The push to reformulate foods with less sodium. New York City has instituted its own goals, and the U.K. has had its own program for years is based on models showing that even small reductions in salt intake can make a big health difference in large populations. Photo: iStockphoto

Last week some experts played down the World Health Organization?s announcement that it was ?very concerned? about the potential health effects of inhaled ash from the Iceland volcano. But we wanted to follow up on that point: can it really be safe to breathe in the same stuff that threatens to destroy jet engines? Ronald Crystal, chief of pulmonary medicine at NewYork-Presbyterian/Weill Cornell Medical Center, tells the Health Blog it’s all in the context. He knows of which he speaks: when Mount St. Helens erupted in 1980, he was then chief of the pulmonary branch of the National Heart, Lung and Blood Institute, and briefed President Carter on potential health consequences. There weren?t a lot of studies specific to volcano eruptions to consult, says Crystal. Instead, he looked at the known impact of inhaling silica. For miners, inhaling silica over many years, at high concentrations, has a definite negative impact: lung diseases including silicosis, also known as pneumonoultramicroscopicsilicavolcanoconiosis (famous for being the longest word in the English language). Crystal says there weren?t any data to suggest that Mount St. Helens produced a comparable threat, and widespread evacuations solely to prevent ash inhalation didn?t take place. After the fact, the population within breathing range of the volcano when it erupted were studied, including kids with still-developing lungs and loggers who were close to the eruption. ?The bottom line,? he says, ?is that there was a little bit of exacerbation of chronic illnesses like bronchitis or asthma.? However, researchers found no long-term effects. We breathe in particles all day long, Crystal says, and our lungs have a ?very efficient mechanism for getting rid of them? called the mucociliary escalator. Mucus catches the particles, and tiny, hairlike cilia move it along so that you either cough up or swallow them. That mucociliary escalator is what?s keeping Europeans? lungs clear of silica, even where ash is falling to ground level. As with Mount St. Helens, people with respiratory illnesses may find their symptoms triggered in the short term, but for others, he says, it?s not likely to be a big deal. Image: Bloomberg News

The winners have crossed the finish line of the Boston Marathon, but thousands of other athletes are still running (minus the few hundred who couldn't make it from Europe due to volcano-induced travel problems).

The debate over whether running marathons is a fine form of exercise or dangerous to your health, however, isn?t likely to stop any time soon; arguing the pros and cons of long-distance running is practically a sport in itself. The Boston Globe takes a look at the ?calamities small or large? that can afflict runners during the 26.2-mile event. The story mostly focuses on the less serious problems ? muscle cramps, tendinitis, blisters, banged-up toenails ? that are a pain, but aren?t going to kill you.

More serious and rare are the problems caused by heat (not a problem in this year?s race, where temperatures were in the 40s), humidity and overdrinking. And there?s much debate about the effects of marathon running on the heart. As the NYT reported last fall, some small studies have shown that a significant chunk of runners show elevated blood levels of troponin, a marker of muscle damage that appears after a heart attack, following a marathon.

But, runners, don?t freak out: that damage seems to fade away after the race. As the lead author of one of the troponin studies told the NYT, the majority of runners are almost certainly doing [their] heart a favor.? Obviously, though, if you experience cardiac symptoms while racing or doing any other form of exercise, it?s time to wrap it up and get medical help. And if you’re a middle-aged male with risk factors for heart problems, a frank conversation with your doctor before you commit to a marathon is a good idea.

Finally, while the marathon is increasingly popular with even people new to running, the exercise habit is more important than any given race.  As the WSJ reported last fall, marathons are often the fitness equivalent of crash diets, with few participants sticking to the kind of routine that continues over a lifetime.

Image: Getty Images

The top reasons cited for making a trip overseas to seek medical care, according to recent studies, are the following:

1. Price – yes, of course. This is the factor that all those discussing medical tourism talk about first, the low prices, often one-third to one-tenth of the price for the same procedures in the U.S. or western Europe.

2. Service – this is one of the factors that most international patients don’t think about in advance but are so pleasantly surprised when they receive treatment. At the overseas medical centers the service is delivered with smiles and hospitality so unlike that received in western hospitals where staff are overworked, too busy, or simply cold and uncaring.

3. Quality – this certainly must be one of the most important reason, although it isn’t always mentioned first. Desparate patients who feel compelled to travel for health care might be willing to accept lower quality if it means the difference between having a medical procedure or not. But more seasoned medical tourists know that the quality of care is often much better than they can get in their home countries, frequently as a result of the issues exeperienced with Service. At the international medical destinations the top doctors spend significant time on each patients’ case rather than rushing from one patient to the next.

4. Availability – this is the infamous waiting time problem that people in countries with nationalized health care experience. Even for life saving procedures, patients often have long wait times, sometimes too long. In overseas medical hubs a patient can walk in to a hospital and arrange for examination and surgery in a matter or days, maybe even hours. There is also the issue of certain medical services that are not available in some countries due to legal or political obstacles. Some IVF procedures have been banned in western countries on religious grounds, and life-saving cardiac stem cell therapy was never approved in some countries but available overseas. Delays in the approval of new drugs or procedures due to government agency backlog and political meddling are another reason people travel for health care.

5. Vacation – is icing on the cake. Take a trip overseas to an exotic destination for cosmetic surgery and then relax while recuperating in a luxury resort. Lifestyles of the jetsetters is affordable to the middle class. What you save on the cost of the medical care more than pays for the vacation.

Lots of statistics were thrown around during the debate of the health care reform bill. The favorite statistic was the large number of Americans who have no health care insurance. The who debate ignores the very function of insurance, which is to cover unexpected castrophic events and not expected or normal events. So the debate itself begins flawed and gets worse from there. Some other statistics are interesting, however.

Studies show that 62% of all personal bankruptcies in the U.S. give the primary reason as medical expenses. The U.S. spends more on health care per capita than any other UN member nation, yet is ranked 37th among developed nations in quality of health care by one UN study. It is painfully obvious that the issue is the cost, yet nothing meaningful is being done to address the cost side of the problem.