North Jersey hospitals struggle with medical tourists
Sunday, June 10, 2007
By MARY JO LAYTON
North Jersey hospitals are treating increasing numbers of foreigners who travel to the U.S. for medical care -- and leave without paying their bill.
Mindful that U.S. emergency rooms must take all comers, these medical tourists head from the airport straight to the hospital -- sometimes armed with CT scans and doctor's notes. As soon as they're well, they're back on the plane home.
They're leaving hospitals -- and taxpayers -- on the hook for millions at a time when 40 percent of the state's hospitals are operating in the red.
Hospital executives report numerous cases, including:
# Holy Name Hospital provided $1.9 million in care to a 67-year-old woman from the Dominican Republic, an accident victim whose desperate son maxed out his credit cards to fly his mother here for treatment. The Teaneck hospital also lost hundreds of thousands caring for patients from Trinidad, Korea and the Philippines.
# A woman from Peru showed up at Hackensack University Medical Center after her doctors at home found a growth on her liver. A patient from India flew in for open-heart surgery, and a man from Ecuador arrived in the emergency room in need of an operation for an aortic aneurysm. The cost for caring for the three patients: $515,000.
# Several area hospitals have seen a growing number of foreign patients in their maternity wards -- including a doctor from Egypt -- who clearly have the means to pay. They get more than free care: Their newborns are granted citizenship.
"We're beginning to hear more and more from hospitals about illegal aliens basically taking a flight in, being treated and taking off back home and leaving hospitals with the bill," said Ron Czajkowski, a vice president of the New Jersey Hospital Association.
"There are apparently cases of individuals who figured out how to take advantage of the system," Czajkowski said.
Many are encouraged to come by family members living in the area -- relatives who know the quality of cardiac or cancer care offered by the region's best hospitals.
Some of the sick wage an epic effort to get here because their own country's health care system can't help them. They scrape together airfare, and they travel in dire health looking for treatment in the land of hope. In other cases, savvy patients select the hospital that specializes in treating their ailment, book a flight, then take a taxi straight to the emergency room -- keenly aware that federal law requires U.S. hospitals to provide emergency treatment regardless of a patient's legal status or ability to pay.
These cases are prompting philosophical and financial debates in emergency departments and hospital board rooms: If they continue to treat emergency patients in all circumstances, are hospitals risking their own financial health? Is it fair to let foreigners leave mounds of debt when citizens face legal action if they don't pay their medical bills? Should the U.S. continue treating medical tourists who don't pay when nearly 47 million Americans don't have health insurance?
"I don't think it is right for people to fly in here from other countries to get care and we don't get paid for it," said John Ferguson, president of Hackensack hospital.
To be sure, medical tourists represent just a fraction of the population of uninsured non-citizens treated in hospitals. But the growing trend is worrisome in North Jersey, one of the most ethnically diverse regions in the country. Hospitals here have aggressively marketed their award-winning treatments, only to find they're attracting more than just residents with health insurance.
"We're a victim of our own success," said Doug Duchak, president and CEO of Englewood Hospital and Medical Center, which recently provided cardiac bypass surgery to a woman from the Philippines at a cost of $43,000.
New Jersey's 80 hospitals spend an estimated $300 million annually to treat illegal aliens, Czajkowski said. In return, they received $5 million in aid from the federal government.
A very small portion of those costs is reimbursed through the state charity-care program. Medicaid can sometimes be tapped for these bills, but in most cases, hospitals must absorb the costs.
Hospital administrators say the rising volume of medical tourists and other charity cases seems unsustainable.
In Hackensack, charity care costs increased 25 percent last year -- causing a financial strain that contributed to a decision to cut $14 million from the hospital's $1 billion budget, Ferguson said.
"If this doesn't stop, hospitals will go bankrupt," Ferguson said.
They already have in California, where 84 hospitals have closed, overwhelmed by free health care to non-citizens.
Milking the system
In a state where nearly 1.3 million residents are uninsured and often go without care, it's the image of the foreign patient jetting in for free high-quality treatment that really irks hospital administrators.
In cancer care, kidney dialysis and maternity wards at Hackensack, foreign patients receive treatment -- in some cases for months -- free of charge. In a one-month period recently, women from the Dominican Republic, Haiti and French Guiana had their babies at the hospital -- and walked out on bills exceeding $130,000 combined, spokeswoman Anne Marie Campbell said.
Although some are destitute, hospital executives said others could easily pay. Members of a wealthy Middle Eastern family have routinely flown to New Jersey to have their babies at Hackensack, said Marianne Auriemma, an attorney who represented one of the family members in a divorce case.
"They have their babies on charity care," she said. "The father drives a Mercedes.
"The taxpayers are getting ripped off. They're robbing and stealing from us," she said. "We have our own people who aren't getting quality care. Do you know how many of my clients don't have health insurance and they're U.S. citizens and have jobs?"
In many cases, physicians say these foreign patients would most likely die or receive inferior care in their own countries.
"A lot of patients are smart enough to realize they have medical situations that are getting worse," said Dr. Joseph Feldman, chairman of the emergency trauma department at Hackensack.
Doctors and nurses empathize at times with desperate families who are just trying to save a loved-one's life. When a Dominican man rescued his dying mother and brought her to Holy Name, the nurses were touched by his overwhelming devotion.
"He was quite heroic," said Dr. Craig Hersh, the hospital's assistant vice president of medical affairs.
Holy Name recently treated two patients -- one from Trinidad, another from the Philippines -- who were near kidney failure when they arrived and needed dialysis and surgery, said vice president and spokeswoman Jane Ellis.
"You typically don't wake up in kidney failure," Ellis said. "Something went terribly wrong at home and they realized they better get to the U.S. where they can get help."
At Hackensack, Dr. Peter Gross recalled how his 68-year-old patient from Peru had CT scans and other tests done at home that confirmed a growth about the size of a small football.
"They did nothing about it," he said of the doctors in Peru.
She arrived at Hackensack and had surgery last fall. By the time she was discharged 26 days later, her bill totaled more than $40,000. She remained in the area and tried to get the hospital to provide free follow-up care -- which it refused, Gross said.
One of the more memorable cases at St. Clare's Hospital in Denville involved a patient from South America who arrived from the airport in kidney failure, said Ben Martin, hospital spokesman.
"He flew into the states for the purpose of receiving charitable medical care," said Martin "There was no pretense about it. That was really what he came for."
Many such patients are encouraged to come by relatives living here, said Ken Morris, director of government affairs at St. Joseph's Hospital and Medical Center in Paterson. He recently received a call from a Paterson resident who planned to fly his mother in from Puerto Rico for cardiac treatment.
"He told me straight out that the cost of treatment in Puerto Rico was too expensive for the family," said Morris, who is also Paterson City Council president.
"It was cheaper for them to pay for a round-trip ticket and receive free care at St. Joe's," Morris said. He discouraged the man from adding his mother to the ranks of charity care patients at a hospital that is already the third largest provider of care for the uninsured and underinsured.
'At their mercy'
Many of these patients arrive in the United States on travel visas. Others come in illegally. When they show up at the emergency room, they -- like all patients -- are asked for identification and insurance cards. In most cases, they say they fell ill while visiting relatives or on a vacation.
It may not be clear right away that they have no intention of paying and it doesn't matter -- they are entitled to emergency treatment.
"We provide care to anybody regardless of the ability to pay," said Holy Name's Ellis. "It's our mission as a Catholic hospital."
Case managers continually seek documentation like passports and other identification for foreign patients. But even when they suspect a patient has means, there's little case managers can do when these patients insist they have no money or insurance.
"You're really at their mercy," said one hospital official.
"In Bergen County, you can get half a million dollars worth of cancer care for the price of a $500 plane ticket," the official said.
U.S. citizens face collection agencies and lawsuits if they fail to pay their medical bills. Yet hospitals often let medical tourist cases go because it's not cost-effective to chase after debt in other countries.
One hospital executive considered suing an Egyptian doctor who delivered her baby in a Bergen County hospital with no intention of paying the bill. In what hospital officials described as a final act of chutzpah, the woman demanded the hospital provide a free checkup for her newborn before she would fly home.
In the end, the hospital decided it didn't make sense financially to try to track her to the Middle East.
Case managers from several hospitals detailed many other headaches with medical tourists: Hospitals get stuck with patients who are no longer acutely ill, but are too sick to travel thousands of miles home; sometimes, families can't or won't take their relative home; some patients need rehabilitation or nursing home care but those places aren't bound by the same law to take all comers. Since Medicaid and charity care won't cover rehab or nursing home costs for foreigners and other non-citizens, patients end up staying at the hospital for months.
In extreme cases, hospitals go to court to evict these patients -- litigation that can turn ugly, as Hackensack hospital learned.
After treating Gustavo Segovia for 3½ months for an aortic aneurysm -- the bill for his surgery and care came to $315,000-- Hackensack officials said they couldn't get his family to agree to a discharge.
The hospital went to court to have the Ecuadorean removed.
Segovia was discharged in September. But just two hours after an ambulance dropped him off at an apartment in Little Ferry, he became so sick another ambulance was called. He was taken to Holy Name, where doctors found him feverish, in respiratory distress and suffering from severe bed sores.
That's when Holy Name went to court -- accusing Hackensack of dumping an extremely ill -- and costly -- patient on them. Segovia spent more than three months at Holy Name, receiving more than $80,000 in care.
The case settled in January when Hackensack paid $45,000 to fly Segovia back to Ecuador on a specialized medical plane. The hospital also paid $10,000 for 15 days of treatment in Ecuador.
Paying for a flight is often the coda to these complicated cases. When the hospital tab is growing at $1,000 or more a day, many case managers say it's cheaper to pay to fly a stable patient home.
Dianna Di Girolamo, executive director of Community Resource Council in Hackensack, a non-profit aid agency, said she sees the desperation in patients seeking care for themselves or family members.
"I don't think these people want to cheat America," said Di Girolamo, who is frequently called when non-citizens need care. "They want to be helped."
These are cases like the 67-year-old woman from the Dominican Republic who arrived "near death" at Holy Name in 2005 and would spend the next 401 days as a patient there.
The woman had suffered head trauma, a broken hip and other serious injuries in a mo-ped accident in her native country, Hersh said.
The woman's son, a Cliffside Park resident, was frantic to save her life. He pooled money with his relatives and from his credit cards and accompanied his mother on the trip to New Jersey.
"She was not breathing well and could not sit up," Hersh said. "The condition we received her in ... we don't know how he did it."
She arrived with wires hanging out of her hip from an orthopedic surgery. She was unresponsive, had dangerously low blood pressure and a potentially lethal heart arrhythmia. She was in extreme kidney failure.
In the intensive care unit, at least 12 specialists treated her, including an orthopedist, cardiologist, vascular surgeon and infectious disease expert. She needed several surgeries. For months, she was unresponsive from the brain injury.
Her bill would eventually reach $1.9 million. Medicaid would pay just $78,000, hospital officials said.
On the one-year anniversary of her arrival, she made a "miraculous" recovery, Hersh recalled.
He found her sitting up in a chair, even wearing lipstick.
"I spoke to her in Spanish and said, 'It's nice to meet you. Now it's time to go,' " he said, laughing.
Hospital social workers talked to the son about making discharge arrangements. But the son shared a one-bedroom apartment with six people. He said he had no room for his mother.
He also said he had no money.
Holy Name paid for her flight home.
* * *
Here are a few of the tabs left behind at New Jersey hospitals by patients from the Dominican Republic, Haiti, the Philippines, Peru, Ecuador, Trinidad and Egypt.
Multiple surgeries, extended care $1.9 million
Surgery to repair aortic aneurysm $315,000
Coronary bypass surgery $43,000
Treatment for a liver abscess $40,000
Labor and delivery (complicated) $42,824
Treatment for kidney failure $55,000
Pediatric checkup $75