Having “Urgent” but not “Emergency” Surgery in the Philippines, Part 2

Dr. Angliongto-Ramos, head of plastic surgery, with a nurse in Bob’s room

My friend Bob interrupted his one-year trip through Southeast Asia in order to have a large carcinoma removed at The Medical City in Manila. This interview took place at my home in Quezon City. The story of the decision-making and the successful outcome appears in Part 1. Part 2 deals with post-surgery care and the conflict with his US insurance company. In an email to me, Dr. Angliongto-Ramos writes, The blog has been making the rounds in the hospital and Bob’s concerns are being looked into. I am pleased with how Bob’s surgery turned out. I hope it was an overall good experience.” Yes, indeed, Bob found his experience at Medical City overwhelmingly positive.

It will be interesting to see what effect cases like Bob’s have in the future as Americans choose to have surgery overseas. I’m predicting that US insurance, healthcare and malpractice industries will close ranks to protect themselves from foreign competition at one-tenth the cost–how bizarrely, I can only guess. A couple of years ago I attended meetings with Filipino-Americans campaigning to have Medicare available to US citizens living in the Philippines. But then someone speaking as an expert said, “Not only is this a long shot, but the doctors would have to have malpractice insurance.” That did it for me.

Bob’s story

Across the road to McDonald’s

After the surgery I was very careful. When you’re 65 years old and paying for surgery yourself, you don’t want to screw it up. Dr. Angliongto-Ramos practices at three hospitals, so she’s got a lot of experience, and she’s very conscientious about avoiding infection. Because she’d done a flap operation and not a skin graft, I only had to stay in the hospital for four days. On the second day I was allowed to get up to go to the bathroom. On the third I could go across the open courtyard to Starbucks. Instead I broke the rules and crossed the road to McDonald’s because the WiFi was better.

My defection led to an international incident with the security guard who saw my hospital ID bracelet and tried to block my path. I was having none of it. He followed me. While I was inside McDonald’s on Facebook, the first guard and his boss were outside on their walkie-talkies. Another guard monitored me through the plate glass. They were trying to figure out a strategy because I was not going to be taken alive. All of these guys were impeccably dressed and ready for the most demanding of inspections. The supervisor was a big bruiser who assessed the situation and finally came in. We shook hands, and I invited him to sit down. He asked to see my ID, and I asked to see his, which he wasn’t prepared for.

He said, “Why are you here?”

Medical City tower as seen from a table outside McDonald’s

“Because the Internet at Starbucks sucks.”

“We have Internet at the hospital.”

“That’s even worse.”

He understood. “Are you going farther than this?’

“No, this is as far as I go. I promise you. I can see my room from here.” I pointed out the tower. “I will go no further. And I am coming right back. I am not trying to escape.”


We shook hands. He patted me on the shoulder and gave me a big smile. I apologized through the glass to the first guy. Everything was fine. I did worry a bit that Dr. Angliongto-Ramos was going to hear about it because she was responsible for injecting this foreigner into the system. So I did what I could–I apologized to the people of the Philippines on Facebook, and I tried to be a better person thereafter.

Bob wearing bandages and drainage tube

The total bill was a shock. It was $5,700, still a huge bargain by comparison with the US, but it took me a bit of processing to get over the difference from the $4,300, the lower of the initial estimates. Before I was discharged, I had a meeting with the surgeon and more testing. She signed my release and met with the desk staff who were preparing my bill. Then I met with the finance department and with the cashier. I paid and got a receipt to submit to the charge nurse on the floor,  who released me. That system is certainly efficient and keeps collection costs down. I was fortunate in having the money available on my Bank of America Travel Rewards Card, which contains an internationally recognized computer security chip.  To my relief the charge went through immediately.

The additional costs came from the many extra biopsies and tests which had to be done because squamos cancer cells–much more serious–were found among the basal cancer cells. Also, the operating room was used two or three hours longer than planned. Imagine all the surgeons and technicians in the operating theater standing around, the patient waiting in the anteroom and finally the anesthesiology team strolling in forty minutes late. When they finally wheeled me into the OR and the anesthesiologist entered, none of us looked at her. We were all silent but polite. I certainly didn’t want to piss off the person putting me to sleep. The extra charges included the longer use of the OR, the extra tests and I suspect the extra nursing care from the staff. Had I understood the Filipino system, I would have had a companion with me instead of making many demands for assistance. Once they understood my situation, the nurses and assistants really went out of their way to help me.

My conflict with Blue Cross Blue Shield HMO Blue was over a common sense issue, not a legal one.  BCBS’s bureaucracy is so entrenched that in order to satisfy their definitions of coverage–definitions which disagree both with my US doctor and within BCBS itself–it sacrificed huge savings both to the company and to me.  It was a word game: “emergency” versus “urgent.” Despite the enormous savings, urgently needed surgery was not covered if done overseas. They chose to focus not on my large, bleeding, bursting carcinoma but on what part of the hospital admitted me and where the biopsies and surgery recommendations were coming from.  When surgery became necessary, we’d lined up Dr. Angliongto-Ramos. Then I saw what a bargain the surgery would be and asked my wife, her company’s BCBS liaison, to contact BCBS HMO Blue to see if they would authorize overseas surgery at a leading hospital in the Philippines. Keep in mind that BCBS is a major insurer in the Philippines, so the local staff could easily have verified that the hospital was excellent and the surgeon very highly qualified. Instead BCBS looked at the computerized decision tree that insurance companies train their staff to use in order to pay the minimum number of claims at the lowest cost. Any variation from the standard falls on the patient. This network of prepared questions is designed to take claimants where the company wants them to go.

The insurance representatives had charts. They knew what the surgery would likely cost in the US and in the Philippines, they had the dimensions of the carcinoma, they had photos, they had all the information they needed to make an informed decision. Instead of factoring in the cost, they kept saying, “Come back to the US for the surgery, and we’ll cover it.” The ridiculous thing was that for me the BCBS deductibles and the cost of going back to the States far exceeded the total cost of the surgery in the Philippines. My family doctor, in a very long conversation with them, was also unable to persuade them to accept the surgery as an emergency and cover it. In order to satisfy a processing clerk in the US, I was advised to instruct this leading Filipino hospital to play silly, unprofessional games like writing “emergency” into every service order. My surgeon in Manila should conspire with the emergency department to admit me on an emergency basis, to have biopsies done in the ER and to have me checked into the hospital from the ER. At every turn it should be classified emergency, emergency, emergency. Even then coverage was not guaranteed. None of this smelled right from the beginning.

The scar and draining tube

Dr. Angliongto-Ramos was so generous with her time. Her office hours don’t start until four p.m. because she’s done six to eight hours of surgery before that. She didn’t take a vacation last year. And BCBS said she should plan out this whole ruse? It was just absurd. I did run it by her. She listened, but I could tell she was going into a slow burn herself. She’s had previous experience with American insurance companies and with their attitudes, the ignorant assumption that everything in the Philippines is like jungle surgery, with doctors eating greasy pork with the fingers of one hand and operating with the other. It’s humiliating. She’s a leading plastic surgeon, practicing in three hospitals. Now she’s supposed to call a junior functionary at BCBS from her home at night—there’s a thirteen-hour time difference—to create this artificial construct, then write up reports that only an idiot, certainly not a medical school graduate, would believe? So the insurance people in the US would have a good laugh over the stupidity of these people in the Philippines, writing something up as an emergency that doesn’t fit? I was embarrassed for having asked her. I’m really glad she took offense and absolutely refused.

I’ve heard estimates from the high $20,000’s to low $100,000’s for this surgery and hospitalization in the US. With all the tests I had done, I can see it’s far north of $29,000 and maybe not too far south of $100.000 that I saved BCBS. They’re getting excellent premiums for insuring my body, not the location at which I have something done. They can’t get out of their own way. If I don’t deal with them again in my life I’ll be only too happy—and that is what I feel about the entire medical system in the United States.  I would have all my surgeries for the rest of my life at Medical City if I could.

How to apply the bandages

Someone who’s never lived overseas might be taken aback by the cultural differences in care and communication. Here there might be information you don’t get which the doctor doesn’t think it’s necessary to tell you and other information which seems far too technical for a patient to absorb.  There are also systems which are routine in the Philippines which are different from US routines that they don’t think to mention. The systems of floor doctors and assigned doctors are different. I don’t think one is better or worse than the other.  I was surprised to learn that there are routine procedures, such as dealing with catheters or dispensing medication that only doctors are allowed to perform at Medical City, but I will tell you that my surgeon saw me three times before the surgery, every single day in the hospital, in the late afternoon or at seven at night. I don’t know where she got her energy. On the discharge day she spent quite a bit of time with me and with the staff getting me cleared for dismissal. And she saw me for times in the ensuing five weeks at no additional charge.

I’d thought in two weeks I’d be on my way, but she knew from the beginning that the first three weeks would be very delicate and require strict germ control and antiseptic procedures and that it would be a minimum of six weeks before I could resume full activities. I had very thorough visits with her. She did a lot of care herself, like inspecting, de-scabbing and re-sterilizing the area, reapplying the bandages and changing the types of bandages and elastic pressure bandages. She taught me how to apply them and Carol how to do the things I couldn’t see, mostly applying disinfectant and things like that. She didn’t charge me for follow-up visit or for medical supplies that aren’t cheap anywhere. Her whole share of the $5700 fee was $1000. The anesthesiology team’s fee was only $500.

As I said, the biopsies revealed a second type of cancer cell. The tests for those took fourteen days. Then I found out that on top of that one-millimeter basal cell carcinoma I had a squamous cell carcinoma–on top, but not reaching in. Squamos is a still treatable but much more serious form of cancer that does metastasize, although it’s far more treatable than a metastasized melanoma. Dr. Angliongto-Ramos was constantly testing my lymph system. Metastasizing cancers go first to the lymph nodes, then to the lungs, to the liver and kidneys and other vital organs and then to the bone. So if you have a squamous cell that’s metastasized, you’re likely to become a stage-four cancer patient. Fifteen percent of people diagnosed with stage four-cancer are still alive a year after diagnosis and one percent are still alive five years later. I’ve had two friends diagnosed with stage-four cancer, and they were both dead within months. So I’d been flirting with a possible death sentence and didn’t know it.

The pressure bandages

Fortunately, all the pre-screening and post-screening tests were exactly the right ones to rule out any metastasizing squamous cells in my body after the surgery. Migrated cells would have shown up on the chest x-rays. Anyway, it was enough to throw a scare into me. I’m not the doctor I think I am. I get too blasé about things. I have no patience with ill health. I really believe that staying mentally positive has given me a great quality of life. I don’t go running to the doctor for an antibiotic every time I sniffle or get a hacking cough.

If I were to have surgery again I would probably have it done in Korea. Nearly 100% of Korean doctors went to medical school in the US. Their reports use the same formats, so I can read the results of a blood test by looking at the US heading. Plus, Korea was my second home for over ten years. In order of preference I’d put Korea first and certainly the Philippines second. Singapore would be too expensive. Then probably India, where some modern hospitals are dedicated to medical tourism, which I would highly recommend. The savings are phenomenal.

I should add that Korean doctors hate to be questioned by anybody. Confucian society holds that you don’t question educated people at all. Everything they say is true and they possess profound knowledge that mere mortals don’t. Historically, doctors in the Confucian countries–China, Korea, Japan–were trained to protect you from yourself, not to tell you when you were dying of cancer, not to discuss what was wrong with you, only to tell you what treatment plan to follow, and sometimes not even to tell your family. The doctor knows best.

Once I stopped by a Korean hospital to get some antibiotic salve. The young, American-trained doctor asked how I knew what salve to request.  I said, “Well, it’s only pink eye. It’s not the end of the world.”

He snapped, “Where did you get your medical degree?”

I snapped right back, “Do you think that doctors own all the medical information in the world? Do you think that people should not be allowed to have the medical information they need and pay for? It’s out there. Live with it.”

He was furious. But things are changing. As Koreans travel and return to Korea, they have a different expectation of the doctor. As doctors are trained in the US, they understand that there’s a different way of doing things which involve making a patient a partner in their own recovery.  Many are starting do take that on board.

A big part of the savings in getting healthcare outside the US is that the doctors are not paying hundreds of thousands of dollars every year for medical malpractice insurance.  Dr. Angliongto-Ramos pays no malpractice insurance. She doesn’t need it. Even if a plaintiff won an award, the award wouldn’t be significant. Here people have to accept responsibility for their own decisions and behavior—spilling hot coffee on themselves at McDonald’s, for example. The medical malpractice industry in the US has become absurd and it places a huge cost burden on the healthcare industry. It’s layered and appears in every aspect. The Band-Aid you get in the hospital is $20 because the manufacturer is being covered against claims for failure to maintain an antiseptic environment. The hospital is being covered against claims of improper storage and handling. We need national health insurance. Then all this malpractice insurance scamming and greedy patients going for the malpractice lottery grand prize will disappear. It’s the golden rule: he who has the gold gets to make the rules. If you’ve got one entity, the US government, paying for healthcare, then the laws would quickly contour to fit. You can’t sue over a free lunch that you didn’t enjoy.

So that’s my ten cents worth on the subject!

Post script:

Here’s my (Carol’s) post on eye surgery after the first one or two. I’ve had sixteen in total, all at the expert and caring hands of Dr. Milagros Arroyo, who is also connected with Medical City.  “The Eye Thing.” (Link) Three-fourths of all cost connected with my macular degeneration was paid without argument by Pacific Cross, which is associated with Blue Cross Blue Shield. Years earlier I had a $2,000 gall-bladder operation in Seoul. Korean National Health Insurance paid half, and Pacific Cross paid the other half.

For a completely different surgery-in-Asia experience, check out “Robert’s Appendix,” which happened in a small town Chinese hospital thirty years ago. (Link)

A Medical City doctor writes:

Yes I read it and enjoyed it very much also. Had a funny moment when Bob, in response to the guard who followed him at McDonald’s said the internet in the hospital was even worse! Oh he speaks the truth. Anyway, what a folly the Health Insurance is indeed. I do hope it gets better so that it can also be availed of with less hassle here.
I doubt seriously that insurance private insurance will improve in the US. The companies have too many lawmakers in their pockets, and state control of the industry means only piecemeal reform. As I said in the intro to that piece, I suspect the insurance industry will put up more barriers against medical tourism when they get threatened. That’s why we need comprehensive reform in the US with a single-payers system of the type you find in Europe, Canada, Australia, New Zealand…
 A reader writes:

I live in Taiwan. On April 16 I went to the emergency room at Xinwu Clinic and immediately saw a physician. I’d made two previous visits to the clinic and received 36 pills and four containers of cream for cellulitis. On this visit I was told I had an abscess. I was given super antibiotics and pain pills that proved too strong. Three days later I had a 30-minute incision and drainage procedure in the ER and was handed four bags of meds. Five hours after that, I had the bandage changed there. The total bill for the clinic visits and surgery was 600 Taiwan New Dollars or $18 US dollars. In contrast, in the ER at Desert Springs Hospital in Las Vegas, Nevada, I was wrongly diagnosed with cellulitis of the eye, treated and billed $2,000. This was later negotiated down to $800 after the county hospital UMC advised that the condition was in fact pink eye.

A reader writes:

Interesting, but I did think your friend Bob played a little fast and loose with his health.