The two biggest obstacles to financial independence are inflation and healthcare — yet military veterans and retirees seem to have more options for dealing with inflation.
The Patient Protection and Affordable Care Act gives the American medical system a strong incentive to reduce expenses. The military Tricare system is also struggling to control expenses, but unfortunately military retirees are paying more for Tricare Prime– if they’re even eligible for an “upgrade” from Tricare Standard. Military veterans are nudged away from PPACA insurance exchanges to use all of their veteran’s benefits through VA clinics. Whether they’re willing to pay for a civilian policy or qualify for subsidies by their income levels, their veteran’s status could mean that they’re not eligible for any subsidy. “Reducing healthcare expenses” seems to mean fewer services and more billing.
I’ve been a military retiree for almost 12 years, and we’ve been eligible for Tricare Prime the entire time. (Oahu is a 30×40-mile island with several military treatment facilities.) Tricare has generally given excellent healthcare inside the doctor’s office, but it’s always been a challenge to persuade the Tricare bureaucracy to let you into that office. You’ll be treated when you’re sick or injured, but if you’re worried about your cholesterol or your breathing or your general health then you’re much more likely to get what the system calls “education and reassurance”. That includes plenty of actuarial statistics and guidelines for healthy living, but you probably won’t be approved for diagnostic exams unless there’s a significant family risk history. “Keeping an eye out for problems” is not considered worth the expense. Financially I understand the rules. Emotionally, though, I’m not so happy.
When I was on active duty I endured frequent “routine” physical exams (whether I felt that I needed them or not) yet in retirement I rarely have the privilege of being monitored for those same routine parameters. DoD has to keep the troops fit to fight, but they’re not spending as much time keeping veterans fit to receive our benefits. Perhaps that’s the way it should be. However, the system spent over two decades of my adult life gathering data on me, and now it won’t do that as much. Yet I’m a nuclear-trained submariner– I love taking logs and analyzing the trends, and I’m reluctant to give that up.
I didn’t worry much about my health in my 20s or my 30s because I was invulnerable. Heck, I was darn near immortal. However, I’m 53 years old now, and a few of my fellow invulnerable & immortal college classmates are waking up dead or expiring during their workouts. That tends to occupy your attention when you’re going to sleep– or trying to work out. My family history also has a few zingers that I’d prefer to have medical technology keep an eye on. If I’m tracking my medical issues, then I’m going to be that much more motivated to live the lifestyle necessary to control them. We can debate the cost-effectiveness of evidence-based medicine, but when it comes to getting regular feedback and sleeping comfortably at night then I’d prefer to spend a little more money.
One solution is supplemental health insurance– if you want more exams and tests then you have to be willing to pay for it. I’ve checked the premiums, and as near as I can tell they’re the cost of the exams plus an additional fee for the insurance infrastructure. It also puts you at the mercy of a second healthcare bureaucracy, and I’m not sure that I want to be squeezed from both sides.
However, another option is concierge medicine. This a refreshingly capitalistic situation: you pay a fee for the doctor’s attention, and they agree to make more time for you. If you want care beyond that, then you tell them what you want and they’ll tell you what it costs. Now you’re paying for professional advice instead of bickering with cost-control gatekeepers.
Our family finances are doing well these days, and I like sleeping comfortably at night. (Especially the part where I wake up the next morning.) However, American concierge healthcare can cost thousands of dollars a year because you’re paying for the system’s higher expenses of labor, liability, and research & development. It’s also tough to shop around for a better deal on a 30×40-mile island.
On Oahu the retail price of a basic urinalysis screening can run close to $100 (plus an hour of your time) and several days to learn the results. A complete blood workup might cost a little more. Did you want a chest X-ray or an EKG with that? Would you like to see a doctor to help you interpret the numbers? Ah, now your exam price is pushing four figures.
But you’ve read the title of this post– you see where this is going.
Last month we enjoyed a three-week family vacation in Bangkok, and our lodgings were right across the street from Bumrungrad Hospital. I’ve read about medical tourism on Billy & Akaisha Kaderli’s website, and I decided to learn more about their physical exams for a future trip. I was a little reluctant to start the process because checking American healthcare prices is a major project and I was expecting a similar gauntlet, along with cultural & language challenges.
I pleasantly surprised. The entire research project took me 10 minutes, and now it can take you two minutes: Bumrungrad Hospital health screening programs. At 32 baht per dollar, a detailed physical costs about $525. That seems like a lot of money for a physical, but click on that link to see what you get for the price. It’s been 20 years since my last chest X-ray, let alone a “whole abdomen ultrasound” along with an EKG and a treadmill stress test.
Military veterans remember their induction physicals: long lines, standing around for hours in your underwear, no idea of what just happened or what’s next. Maybe a tech took the time to explain a procedure, but that meant everyone else was waiting on you for their turn. We’re also familiar with the long waits for appointments at military clinics, so I e-mailed them to see how far in advance I’d need to schedule one.
More pleasant surprises: three hours for the tests, the results would be reviewed at the end of the exam, and would this Saturday morning work for me?
Bumrungrad has several large office buildings on a bustling one-block campus. Unlike any American hospital that I’ve ever seen, Bumrungrad’s labor is cheap and they’ve made a huge investment in information technology.
Better yet, it’s a great deal for doctors because Bangkok’s cost of living is a fraction of any major American city. A doctor with an American medical degree is welcome almost anywhere in the world, but their salary goes a lot further in Bangkok. They’re also surrounded by people who have scored their own excellent jobs and are eager to please, and they have the efficiency tools to boost their productivity. Bumrungrad has a world-class reputation because they’re hiring the best and leveraging their labor in a city where everyone can keep more of their salaries.
We stopped by the hospital a few days before my appointment to look around. The entrance resembles a five-star luxury hotel, not an industrial medical facility– right down to the valets hustling taxis and patients. Instead of being ignored in the lobby (as would happen in a metropolitan American hospital), a concierge was stationed right by the coffee shop. She explained where to go and who to see.
When we stepped off the elevator at the physical exam floor, another concierge suggested that we spend 15 minutes pre-registering now so that we could skip the Saturday-morning crowd. As I filled out the forms, I noticed that several concierges were working the elevators in at least six languages. The monitors showed who was next in multiple languages, and speakers also announced the numbers. When the clerk entered my form into their database, she also took a digital photo that was printed on my “itinerary” and displayed on their monitors. Each time a concierge was ready to escort me to the next station, they could look at the thumbnail image to recognize me instead of shouting my name across the room like a roll call.
Bumrungrad’s website clearly lays out their prep requirements for their physical exam, including fasting and drinking. I asked the concierge whether I should do anything else to get ready for Saturday morning, and she quietly supplied me with a stool-sample kit. Who knows, maybe she’s an American military veteran too.
On Saturday I showed up a few minutes early, and they were ready. During the next two hours I never waited for longer than five minutes. The staff stepped us all briskly through the sequence (including the payment desk, all major credit cards welcome) with quiet efficiency. Every station not only had a half-dozen clerks behind the counter, but also another half-dozen concierge staff working the room to answer questions in multiple languages.
Each exam room had a tech running the procedures, and at the end of several of them (like the EKG) the doctor was brought in right away to check the results for problems or additional tests. The techs and doctors had done literally thousands of exams and were extremely familiar with the medical issues as well as the equipment. (The ultrasound tech even gave me a tour of my trunk and major organs.) I chatted with at least four doctors during the physical, and another doctor for the review. I had plenty of time to ask all the questions I wanted, the techs were happy to brag about their gear, and nobody rushed the patients– but as soon as I was finished, a concierge was ready to walk me to the next stop.
The only paper I saw all morning was my one-page itinerary checklist and an EKG printout. Every other bit of exam data was reviewed on a monitor and then went from the equipment straight into the patient database.
I’ve never had a stress test before. (Other than being a submariner.) The tech slathered electrodes all over my chest, wired me to the data harness, and strapped on the blood-pressure cuff. I walked on a treadmill as the equipment recorded the numbers, and every three minutes the treadmill raised the incline to boost my heart rate to the age-adjusted 85% level. After 10 minutes they’d seen enough. I wasn’t even breathing heavily, let alone sweating, but I passed several exam rooms where patients were working a lot harder. Bumrungrad finds it necessary to inform their clients that the stress test treadmill is limited to 150 kilos.
I counted at least 40 customers during my two-hour circuit, and there were probably more who I never saw. American faces and languages were as common as Middle Eastern, Asian, Russian, and European ones. The clerks & concierges kept hustling, and the techs & doctors never had to go find somebody to fetch something. By 11 AM I was shown into the lobby, asked to help myself to the free snack bar, and told that I might have to wait as long as (*gasp*) 20 minutes before they were ready to review the results with me.
The exam was summarized on a monitor for the doctor and me to review together. (The PDF was e-mailed to me later that day.) My family history was included. He could click through most numbers to get to the actual test, the analysis, and the details. Any number outside the spec was automatically highlighted for further discussion. The EKG printout was scanned into the package for his review. If we had multilingual vocabulary issues or acronym questions then he could whip up a search box. He only had two questions (cholesterol and a liver enzyme) and we sorted through the answers in a few minutes. I had a few more questions, and he took the time to explain his answers.
The doctor was bemused: “You’re perfectly healthy. Why are you here?!?” I explained my age, my exercise-related shortness of breath and pounding heart, and my muscle soreness. My physical capacity was declining, my reflexes were slower, I couldn’t lift as heavy, I couldn’t keep up in taekwondo, and lately I needed at least 48 hours of recovery. 800 mg of ibuprofen almost daily. Even a few hours of surfing would wipe me out for the rest of the morning.
About two minutes into my recital he’d heard enough. He explained the details with technical medical vocabulary, but the surfer’s summary was “Dude. Yer gettin’ old. Welcome to Geezerland. Stop hotdogging it and use a longboard– or go stand-up.“
The good news is that I’m unlikely to wake up dead or collapse during a workout. I could make a few changes: lifting for more reps, not so much for strength. Intense anaerobic intervals, not so much aerobic endurance. Stretching. Yoga. Thai massage. Ibuprofen and other anti-inflammatories as desired. Less sugar, less carbs, more protein, more fiber. Maybe supplements. If you were alive during the Kennedy administration then you’ve heard it all before.
I may be stuck with my physical limits, but Bumrungrad showed me lots of medical options. The next time we’re in Bangkok I’m bringing 30 years of medical records. I’m going to talk to a pulmonary specialist about acute exposure to volcanic ash and submarine atmosphere-control chemicals, and maybe I’ll buy a lung function test. I’m going to ask the orthopedic surgeon about an MRI update and discuss my knee longevity. I’m going to get an audiogram and a tinnitus talk. We’ll even have the geezer chat about thyroid function, vitamin B12, and other supplements. And while I’m there, I’d like to know whether there’s a better way to do a colonoscopy than my experience with Tripler Army Medical Center. I’d hate to learn that things could have been worse.
If you’re a military servicemember and you’re a little concerned about symptoms that may affect your eligibility for submarine pay (or any other specialty pay), then consider an off-the-record trip to Bumrungrad. You’ll have to burn a week of leave, but a few months of that specialty pay will cover your expenses. You can obtain reassurance and consider your future without feeling stigmatized– and perhaps without the risk of being unfairly benched for further research. I’m sorry that the American active-duty military healthcare system can’t already do this, but its priority is force readiness rather than our personal career issues.
If you’re an American hospital administrator then you need to visit Bumrungrad. If you’re a Hawaii medical professional and you’re not already familiar with Bumrungrad, then your credibility is suspect. Please consider adopting their administrative procedures at your practice.
Best of all, I can stop worrying about medical bureaucracy (and insurance companies) and start managing my longevity.
TRICARE Prime premiums and United Healthcare
The Affordable Care Act and Military Veterans
40 miles for Tricare Prime — or maybe Tricare Standard
I’m still a Tricare delinquent
Tricare fee increases coming in October
How I cost my Dad over $2000 in Medicare benefits
Economic Refugees at RetireEarlyLifestyle.com