No Easy Answers in Bioethics Podcast

Why I Left the U.S. for My Surgical Procedure: Fleck and Fluegel - Episode 21

March 10, 2020 Len Fleck photoLarissa Fluegel

What would you do if you needed surgery, but seeking care would mean $25,000 or more in medical debt? Would you consider traveling to another country to receive the same surgery at a fraction of that cost? Would you put off seeking care entirely, until it became an emergency situation?

These questions related to access to care, health insurance, and medical tourism are explored in this episode, which features Center for Ethics faculty members Len Fleck and Larissa Fluegel. Dr. Fluegel, a clinician born and raised in the Dominican Republic, shares her personal experience of needing gallbladder surgery, and the reasons why she traveled from Michigan to the Dominican Republic to receive that surgery. It may not be surprising that the main reason was cost. Discussing the healthcare systems in both countries, Drs. Fleck and Fluegel explore the challenges that under- and uninsured individuals in the U.S. face when seeking care.

This episode was produced and edited by Liz McDaniel in the Center for Ethics. Music: "While We Walk (2004)" by Antony Raijekov via Free Music Archive, licensed under a Attribution-NonCommercial-ShareAlike License.

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Episode Transcript

Liz McDaniel: Hello and welcome to another episode of No Easy Answers in Bioethics, the podcast from the Center for Ethics and Humanities in the Life Sciences at the Michigan State University College of Human Medicine. Featuring a conversation between Center for Ethics faculty members Len Fleck and Larissa Fluegel, this episode tells a story that involves health insurance, access to care, and medical tourism. Dr. Fluegel, a clinician born and raised in the Dominican Republic, shares her personal experience of needing gallbladder surgery, and the reasons why she traveled from Michigan to the Dominican Republic to receive that surgery. It may not be surprising that the main reason was cost. Discussing the healthcare systems in both countries, Drs. Fleck and Fluegel explore the challenges that under- and uninsured individuals in the U.S. face when seeking care.

Len Fleck: Hello everyone. Welcome to our podcast today. I'm Len Fleck, I am the Acting Director of the Center for Ethics and Humanities in the Life Sciences in the College of Human Medicine at Michigan State University. And today we're going to be speaking with Dr. Larissa Fluegel, who is a faculty member also in the College of Human Medicine in Grand Rapids. We're going to be talking about what might sound like a rather odd topic, namely Dr. Fluegel's gallbladder surgery. But as you'll see, there are some very interesting and distinctive policy-relevant features and ethically-relevant features of her surgery. So we're going to get right into that conversation. So, Dr. Fluegel, one of the things that I'm sure many of your friends have asked you about is that you needed gallbladder surgery, and you went to the Dominican Republic to have your gallbladder surgery done. And so I suspect a lot of your friends say to you, why in the world would you do that? We have many fine surgeons here in the U.S. Why would you go to the Dominican Republic to have your gallbladder surgery done?

Larissa Fluegel: That's right Len. When I, I went to the Dominican Republic this past winter earlier this year, and as I came back I shared with some of my peers and some of my students about my experience, as it actually became relevant in some of our discussions that we had in different activities. And I, I realized that though it sounded to me like sort of obvious why I would do that, I realized that it was not so for, for people. So, it got me thinking about the differences between the system, and my motivations, it got me like really meditating on that, and that sorts of issues.

Len Fleck: So what are the features of your situation that motivated you to want to go to the Dominican Republic for your gallbladder surgery?

Larissa Fluegel: So I would say that the main, main issue was an issue of cost, and affordability for me personally.

Len Fleck: Mm-hmm.

Larissa Fluegel: There was no, not a time that I questioned the effectiveness or even the quality of the care that I would receive here, but it was mostly an awareness of cost.

Len Fleck: So what kind of costs are we talking about? What does it cost, for example, to have gallbladder surgery somewhere in the United States, say, in Grand Rapids.

Larissa Fluegel: So, what I realized as I started doing my research is that for me, if I were to pay out of pocket, gallbladder surgery—and this is probably conservative—but it could be more than maybe 24 to 26,000 dollars. That's mostly cost of surgery, and that might not necessarily include peri-operative costs, meaning before or after surgery. And this is also only laparoscopic surgery.

Len Fleck: So if you had a different kind of surgery, if it required making a major incision, then you'd have a longer recovery period, and it would also require a longer period of hospitalization, and so much higher cost than the 24 to 26,000 dollars that you mentioned, right?

Larissa Fluegel: Correct. So, in my particular case, and I would say this would have been an advantage to me which would have kept my cost on the lower tier would be the fact that my situation was uncomplicated. I had what we would call like a cold gallbladder, meaning that there are no like complications with infection or other things that might require me to have a more complex surgery, meaning open surgery, and then that would require higher cost also.

Len Fleck: Were you at all concerned about the quality of care that you were going to receive in the Dominican Republic? And why the Dominican Republic?

Larissa Fluegel: Okay, okay, so those are two questions. So why the Dominican Republic. I am a Dominican national. I was born and raised in the Dominican Republic. I had received cares all my life there growing up, and as a young adult. I also attended medical school there. And I felt fairly familiar with the system. I felt fairly—at least fairly, if not very confident—that I could discern where I could get good care. And so—did I answer why the Dominican Republic.

Len Fleck: Right.

Larissa Fluegel: What was the other question?

Len Fleck: Yeah, what were your, did you have any concerns-

Larissa Fluegel: Concerns.

Len Fleck: -About the quality of care that you were going to receive there.

Larissa Fluegel: Right. So, I was not. I was not concerned. And that's, um, probably have to do with the fact that I had been in the system. I have navigated the system as an, let's say inside, I had a lot of inside information. [Laughs] I knew people. I, the surgeon that I, I felt like I had options and I could choose. And I had a good amount of information and understanding enough of the system to feel confident and comfortable making a decision as to where I was going to get care, and who would provide for my care. And so the person, my surgeon there is someone that I knew from medical school that was highly recommended, mostly word of mouth by also other people, my peers. And also me looking into his, his experience, experience from other patients, and like that. And I also knew the center where I was going. I know the people who own the center. So all of that gave me confidence in making that decision.

Len Fleck: Now we, I'm going to work back to one of our earlier questions. So the cost of having that surgery in the United States would be 24 to 26,000 dollars plus or minus a few extra thousand dollars. What did it actually cost for you to go to the Dominican Republic to have that surgery done, because I'm sure our listeners would want to know that.

Larissa Fluegel: Right. So, it cost me nearly $3000 or so, give and take. If you were to add cost of flight-

Len Fleck: Mm-hmm.

Larissa Fluegel: -Like getting there, and maybe transportation, and accommodations, it would not be no more than $4000 for my trip and surgery.

Len Fleck: So that represents less than 20 percent of the cost of having that same surgery in the United States, right?

Larissa Fluegel: That's correct, yes.

Len Fleck: Here's... in the Dominican Republic, if, if somebody needed gallbladder surgery, would they, would any citizen of the Dominican Republic have access to that surgery, just as you had access to the surgery.

Larissa Fluegel: I would say, yes. They would have access to the surgery. Conditions of care might vary greatly. From one region to the next, geographically speaking, but also whether it takes place on a metropolitan area like the capital city, which is where I was.

Len Fleck: Mm-hmm.

Larissa Fluegel: Versus any other area around the country, and much more if there's a, let's say rural areas may not have that access, people might have to travel a distance to have the same access that I had.

Len Fleck: Are there citizens of the Dominican Republic who don't have health insurance, who in effect then would not have access to needed health care?

Larissa Fluegel: Okay, so this is a little tricky question. So, technically, every single Dominican citizen as well as foreign a citizens that reside legally there, they have the right to access to care, right. And, there, legally, it is established by law that services need to be provided to people. Everybody. Regardless of your insurance situation, employment situation. There is a public health care system, and there is a private health care system. In my case I went through the private, and I paid out of pocket. Within the private there is people who are employed that are also financing their own health care, they pay for insurance, and there is insurance coverage for them as well. Then there's a public system that is made by also contributions of employed persons. But there is also a subsidized part of the public system. And that is meant to ensure access to every citizen. Regardless of their ability to pay. And so we have throughout the country, which is a small country, different regions. We have public institution, financed both by contribution of employed people, but also the government through the Social Security system. Institutions, specific hospitals that are for anybody to access. Now those places are, this is where most residency programs take place. So there is an guarantee of staff, and adequately trained personnel there. Now there's other limitations that might challenge people's ability to access quality of care. Does that make sense?

Len Fleck: Yeah that makes sense. Now one of the things we wanna talk about is a sort of comparison between the U.S. and the Dominican Republic. The Dominican Republic relative to the U.S. is a relatively poor country, but nevertheless they are guaranteeing access to needed health care for everybody in their society. So, a kind of obvious question I have is that if I were either uninsured or under-insured here in the U.S., and I needed gallbladder surgery, what would happen to me? I'm not eligible for Medicaid, I'm not eligible for Medicare. I may not have any private health insurance because my employer doesn't provide me with private health insurance. Or, I might have one of these bare bones insurance policies with very high co-pays and deductibles and so on. And so I would be responsible for, I take it, a very substantial part of the cost of having that surgery.

Larissa Fluegel: Correct. So, under those circumstances of what you're saying, you're not eligible for financing, federal, state, or any assistance, is that right?

Len Fleck: Yes.

Larissa Fluegel: Which is a big chunk of the population, if I understand correctly. So what would happen to you. One of the things, I would say the first thing that you're gonna do is that you're gonna question whether you're gonna seek care. And you might delay care. You can have a relatively uncomplicated gallbladder situation where you just have stones, cholelithiasis. To, if you let it go long enough, it might become complicated, and put you at risk of other serious illnesses. Let's say pancreatitis, sepsis. Definitely you won't be working, so it will put you down, you won't be able to work. You might lose your job.

Len Fleck: Mm-hmm.

Larissa Fluegel: And those aren't just a stretch unintended consequences. But directly related to health care, if you delay care then you have, you are serving a higher risk of morbidity and mortality, right. So you're putting yourself at risk of even death. [Laughs] And then if you do decide to seek care, one option you may have is to do medical tourism, which is sort of what I did, to seek care in a different country. And by doing that you're submitting yourself to other risks that we can expand on. Or you could seek care here which would mean that you will probably incurred in a huge debt, and financial toxicity because you have to figure out a way to pay for this. In my personal, in my particular case, I probably would've spent the next 20 years paying $200 a month [laughs] to afford this. And that's a little bit of a problem considering that I may not have the financial margin to do that, but even if I did, then I'll have no margin if anything else should happen that would require me to need to finance health care again.

Len Fleck: Okay, now, I know nothing at all about—I've never had a gallbladder problem. So I don't know what it feels like, or how, if I were in the situation of being uninsured or under-insured and faced with outrageous costs for having this treated. You've told me a little bit about the risks I might be taking. Do you have any sense of, how long I, do I have any options other than surgery for dealing with my gallbladder, my imagined gallbladder problem?

Larissa Fluegel: Okay. Well I, I take it that the average person that doesn't have medical training will probably at least need to seek some level of care so that they can have the information that you're, like, that we're gonna discuss right now.

Len Fleck: Mm-hmm.

Larissa Fluegel: So for example I knew I had other options. And so that bought me time. So options would be that I could deal with the pain. So, so when a person has gallbladder stones, a lot of us in the general population are walking around with stones in our gallbladders that are giving us no problems. Like we could die of something else and never have issues with our gallbladder and still have stones there. So, but when they become symptomatic, meaning that they reach like a critical mass, I suppose, they start giving you symptoms and the gallbladder stops doing their function. So your gallbladder's no longer there doing what it's is supposed to be doing, and instead it's causing you a lot of pain. Especially when you eat certain foods that, because the gallbladder, the job of that is to store bile, which has to do with the digestion of fats mostly, but other things, it aids in digestion in general. So when it starts to give you problems, that means that you have issues digesting fats. You have what we call gallbladder colic, which is a very, very, very, very painful process. So every time you eat, within 20 minutes, you have a lot of pain. Abdominal pain. Specifically on that area where the gallbladder is. It's to the point that it hurts when you breathe, and you have to literally stop what you're doing and sit down. Take a breath and wait for it to pass. And it can last anywhere from a few minutes to 20 minutes. Every time you eat, basically. Unless you avoid certain foods that would specifically trigger that colic, that will trigger the gallbladder to contract and to function. Is that—following far? [Laughs]

Len Fleck: Yeah. This sounds awful.

Larissa Fluegel: At least is very painful, if it's not complicated. Now, if I manage, like in my case, I put myself on a strict diet. Which is really an unsustainable diet because I was, because I'm not eating fats, that means that I'm not absorbing—first of all, fats are necessary for human functioning. For hormones and brain function and all of that. But they're also necessary for absorbing certain vitamins that are usually soluble in fat. So if I don't eat fats, then I'm missing on those vitamins, and minerals. So I run the risk over time to be malnourished. Which in fact it almost was happening to me, I lost about 12 pounds in those 2 months period between the time that I knew I needed surgery and until I actually got the surgery. So the, the strict diet is only a temporary measure that shouldn't be prolonged or postponed for too long. But that's an option that buys time. So the diet, and then, if you do get colic then you'll have to manage with pain medication. Thankfully in my case the diet was enough, but for a lot of people when the colic starts it is really painful, almost unbearable. So, some people can be fine by taking acetaminophen, you might need to take ibuprofen which is a little more harsher on your body, to the point that some people might need some maybe morphine or opioid treatment.

Len Fleck: Okay. So, if in my imagined situation, I'm not going to the Dominican Republic because I can't speak Spanish. So I would have to go somewhere else. And so, I would have to pick another country. What are the risks I'm taking? How would I know where to go, who to trust? Are these all challenges that I would face? And, I'm speaking I guess as a relatively well-educated sophisticated individual. For the average American, would they have any idea how to go about doing medical tourism? If even that was affordable for them.

Larissa Fluegel: Right. So, I would say it would depend where you would go. I, speaking from the Dominican Republic which is still under development country. So there's risks. Obviously there is no guarantee of the quality of care. There's no minimal care that can be guaranteed across the board. So from one institution to the other, I could run the risk of poor sanitation conditions. I can get an infection through surgery. I could potentially get treated by a person who's not as skilled in laparoscopic surgery. Who can possibly cut the wrong thing, you know, the wrong structure, anatomically speaking. Or, I get the wrong medication. So, quality of care is a risk. Because there's no guarantee. And since you're not native, you're not there to know what center is good or other—the other thing is that you would think that you might be able to research and get information about the quality of care of different, you know, potential candidates for your surgery. The quality of the data that you may find is also there's no guarantee. Because there's, there are no consistent safe tracking systems that can guarantee to you that the data that you're getting is also reliable.

Len Fleck: Okay. So, I think about this from an economic point of view. I look inside my wallet and I say, I can't even afford the 4000 dollars, 5000 dollars it might cost me between travel and the actual costs of surgery somewhere else in the world. And, and then I remember, oh, here in the United States we have a law called EMTALA, the Emergency Medical Treatment and Labor Act, which says that when I have an emergency condition, I have to be treated at the hospital. So what I imagine is, I guess I'll just wait until my gallbladder is just really, really bad, and is going to do something that could be a threat to my life. And then I'm going to go to the hospital, and am I going to get my care for free then? Because it is an emergency treatment? And, I can actually answer my own question for you. [Laughs]

Larissa Fluegel: [Laughs]

Len Fleck: Which is, no. I would still be responsible for paying for the care that I got. And it's likely to cost me a lot more, if I can afford anything at all, or else the hospital is going to absorb the cost, you'd just have to wait and see what would happen. But I am, even under EMTALA, all, all EMTALA says is they have to treat me. They cannot turn me away because it is an emergency situation. But then I would still be responsible for the cost of that care. Maybe I'd be forced into bankruptcy or something like that. I could lose my home. Lots of other bad things like that could happen to me. How can that happen in a rich country like the U.S. when that isn't going to happen in the Dominican Republic? I mean that's sort of the awful question that we're faced with here.

Larissa Fluegel: That's right Len. So, the fact that I have the right to receive care does that mean it's not gonna cost me or someone else. Even if I have insurance, I would still have to put in a certain amount of money, what could be maybe 15,000 dollars, for me to get that gallbladder surgery in a timely manner.

Len Fleck: Mm-hmm.

Larissa Fluegel: With the, through the insurance system. So, your question, how can that happen in a country of the United States? That's a, that's a loaded question. [Laughs]

Len Fleck: [Laughs] Obviously.

Larissa Fluegel: There's so many factors playing into that. So, I'm not sure. Would you like to start that debate?

Len Fleck: Well we've had that debate for decades now. And apparently we're just not willing to come to some kind of fair and reasonable resolution. That is congruent with what we see as the fundamental values that define what the United States is about. We're probably not going to be able to resolve that over the next couple minutes, but it is at least worth calling attention to the fact that there is this discrepancy in access to care in the United States. And that it can have awful consequences for individuals who are under-insured or uninsured, and have no otherwise personal ability to pay for care that may be needed. And needed in a strong sense. Where, as you pointed out, if you don't have a gallbladder problem addressed, there is the risk of serious morbidity and a risk of mortality, a risk of premature death if that's not adequately treated. With that, I think we have to conclude this particular podcast. We thank all of our listeners for tuning in. We welcome questions that you may have regarding this podcast. Thank you for your attention.

Larissa Fluegel: Thank you, Len.

Len Fleck: Thank you, Larissa.

Liz McDaniel: Thank you for joining us today on No Easy Answers in Bioethics. Please visit us online at bioethics.msu.edu for full episode transcripts and other resources related to this episode. A special thank you to H-Net: Humanities and Social Sciences Online for hosting this series. This episode of No Easy Answers in Bioethics was produced and edited by Liz McDaniel in the Center for Ethics. Music is by Antony Raijekov via Free Music Archive.