Archive for April, 2010

The medical tourism industry seems to be getting kind of confusing. Everybody wants a piece of it. I saw a news story that says 50 countries have declared themselves to be medical tourism destinations. That seems a little optimistic for a lot of them. My Google alert for “medical tourism” yesterday contained links to stories about medical tourism in India, Philippines, Korea, China and even Iran – yeah, Iran even says they will become a medical tourist hot spot.

It’s really confusing when the same countries that people flee to avoid high costs and long wait times come out and say they are going to develop their health care system to attract foreign patients. It seems like they are trying to talk their way out of a bit of a contradiction. In the story about Canada the goal is to help fund the “free” health care of Canadians with fees paid by foreign patients. But that’s a little tricky because they are competing with other established international hospitals that are much lower cost. It seems possible, however, that they could command a premium from U.S. patients because of proximity (lower travel costs and greater convenience) as well a applying lots of FUD (fear, uncertainty and doubt) about seeking treatment in “third world countries” (despite, of course, that many of those overseas hospitals have certifications the Canadian hospitals don’t even have). But it might work. The question is can they find a sweet spot in the pricing that is competitive yet still profitable.

Price controls are great

Posted: April 29, 2010 in Health

I like getting stuff at below market prices. The new health care reform law could help me do that, couldn’t it? I read that the law requires that next year there has to be a procedure for consumers to challenge any rate increase for their insurance plan. The fed is funding states to set up something called “health insurance consumer assistance office” where you can go to file a complaint if your rates go up. Hey, this is great. I think they should also have a “gasoline consumer assistance office”, maybe even a “beer consumer assistance office” (not really, I don’t even drink, but if I did, hey…).

See, once you make it a law that you have to buy something, such as medical insurance, then you have to consider what happens when evil capitalists try to make money by raising prices on that legally-required item. So some sort of process or control has to be put in place. Otherwise you risk people becoming criminals overnight when their insurance company raises their rates and they can’t pay. So another big bureaucratic organization needs to be created. Continued growth of big government. What’s next?

I think I found the answer to my question about whether or not expats would be screwed over by having to buy health insurance under the new health care reform bill. The answer, although not athoritative, is no. It’s not explicitly stated in the bill but it’s a combination of the new law and a new IRS regulation.

The health care reform law says you must meet a minimum level of coverage requirement, and a new IRS regulation says that expats are assumed to have the minimum level of coverage requirement for tax purposes. There appears to be no requirement to prove it and just as well since what would that mean? Expats who live full time in another country take care of their medical care expenses in a variety of ways. It would make no sense to impose U.S. coverage requirements on expats since the costs are completely different.

Expats may achieve adequate coverage from a variety of insurance or membership plans or be self-insured which is to say no coverage at all but just pay out of pocket. That’s the usual case here in Thailand. Top quality care at the private hospitals is a fraction of the cost of U.S. care so many people just pay out of pocket. The total costs for things like major surgery are often less than a single year of premiums in the U.S.

Many of the hospitals offer a sort of membership plan that entitles you to discounts on medical care. It’s sort of like an insurance plan but specific to that hospital. Those memberships can be a good deal under certain circumstances. For example, the Bangkok Hospital Group has a plan that costs around 20,000 baht that offers discounts on doctor visits and inpatient care, as well as free health screenings for three years. If you like that hospital and are definitely planning to do your checkup there every year then it more than pays for itself in the health screenings alone, and the discounts on other treatments are a sort of insurance policy. Sort of, because it doesn’t pay a significant fraction of a major medical bill.

So for now at least expats aren’t going to get screwed over by the new health care law. Just Americans who still live in the U.S. might be one of the more famous Drupal based websites, certainly one of the high profile ones. I’ve just started looking around over there, think I’ll study it a bit to see what I can learn. I saw a blog post that described some Drupal modules they developed and will contribute to the Durpal community.

Being a heavily visited website they need to handle high traffic so developed a couple of modules to address scalability. Something they call “context http headers” adds meta data to content to tell servers how to handle specific pages. Hmm, sounds interesting, not clear on the details however. Another they simply call “akamai”, you know, the big content delivery network that a lot of the really big players use. So this one helps Drupal sites integrate with Akamai.

There is another module they are contributing that is designed to “enable more dynamic emails tailored to users’ preferences”. I don’t know what that means. Maybe I can experience it by joining the mailing list.

And finally there is a module for accessibility that makes sure all images can be read by screen reading software. Good stuff.

I have heard a few criticisms of Drupal along the lines of “Drupal is outdated” and wondered where that was coming from since it has become very popular only relatively recently and there are so many contributions being made all the time, like these from Seems to me there must be hidden agendas there.

That old cliche rings true time and again. I’ve been through numerous rounds of search, hire and fire lately. The one I’m writing about now is my efforts to find a good Drupal developer. This is related to the work I’ve been doing with a good friend who has an online store based on Drupal.

The original design was largely completed by a developer based in the U.S. and there were some serious ethical issues with them. It took us some time to extricate ourselves from the engagement and protect ourselves from some attempts at malicious actions. A new developer had already been engaged when I joined. They were an Indian design house. A few important features remained to be implemented so I worked with the Indian developer to get them done. The experience was frustrating. It would appear that communication had take place and the developer would report work was completed when in fact nothing at all had been done. In other cases they would go off on a tangent and do something that wasn’t even on the list of tasks.

One of the bigger frustrations was that we urgently needed to re-host the site. I had never re-hosted a Drupal site before so I left it to the “experts”. Two weeks it took them. Due to the Network Solutions hosting debacle I posted about before I had to immediately move hosts again. This time I did it myself. It only took me two days and most of that time was waiting for files to transfer on my slow and unreliable internect connection (which I have posted about numerous times before). We terminated that developer.

So we started looking for another Drupal developer. We received a number of recommendations for both domestic and offshore developers. The domestic developers were a nonstarter due to their cost. We wanted to redesign the store, nothing really major, just add improved navigation to the catalog, add some social sharing features, include mailing list signup and product ratings, that sort of thing. Estimates from developers were a couple weeks of effort. For a domestic developer that works out to $5,000 or more, a complete non-starter. Seriously, we have an existing Drupal website that needs a few modules installed and configured and a new taxonomy vocabulary created and added to the store. Thousands of dollars…end of conversation. So we went with another Indian developer that quoted under $1,000.

And the same frustrations. Work reported complete when it wasn’t. Implementations that were questionable. Answers to questions that were plain wrong. They did a SEO analysis and provided some recommendations. Some them were bad recommendations. For example, they recommended change the url alias from to I did a little research on that and found a number of places it was discussed and nowhere that anyone could show an SEO benefit. And over at W3C they recommend against this sort of thing, saying that future-proofing your website means not being explicit about the implementation so adding a file type extension is the wrong thing to do.

If you remember my post about creating a newsletter archive you recall that I used Drupal Views to create a feed from the archive. For some odd reason the developer used a custom php script to create the feed. Sure it works, but that’s another thing to try to keep track of when it comes to maintaining the website. Keeping it all within Drupal is a much better practice.

So after two months to complete what was quoted as a two week job, and failing to complete some of the tasks, I terminated that developer. While they were flailing I began searching again and I got indications of the same kind of behaviors. I provided a spec for quote and the offshore developers (all Indian) gave back completely generic quotes that had nothing to do with the spec. One of them I replied to and asked why that had included a graphic development milestone when there were no graphics to be developed. They answered that the second payment was tied to the completion of graphics…what the? The domestic developers were a different story. They had detailed questions that indicated they had read and understood the spec and they provided details quotations. Unfortunately their costs were around $10,000 for something we expected to be about $2,000.

Since then we have gone without a “real” developer. I have been doing some development myself and the truth is once you get past the Drupal learning curve there are a lot of things you can do without custom programming, or maybe just a little bit of programming to augment or tweak existing modules. There are two open questions in my mind as a result of this experience. First is how the heck to small startups afford a full featured website? It’s easy to throw together a WordPress site that looks cool and has a lot of features but I haven’t seen one that includes a real store. I’m not talking about an affiliate website or a site selling a handful of products and taking payments with PayPal. I mean a store with many products, credit card payments, stock management, sales tax reporting, all the things a real store needs. That takes something like Drupal or maybe a closed source solution that is even more expensive because you pay for expensive software and then pay again for developers.

The other open question in my mind is what is the real state of software development in India? I worked with two developers and evaluated two others and all exhibited the same behaviors. There may have been competent programmers at those companies but there was little evidence in the work performed. The communication is deceptively poor, in that you really are convinced that requirements and tasks are understood but what they end up doing indicates a lack of understanding. I just don’t get how people have successfully used Indian developers.

My little story about trying to stay connected in the jungle that I posted before isn’t finished yet. As I said, I’m still waiting for 3G and ADSL to both become available in my area. I need them both because neither is reliable enough to count on as my only internet connection. The last couple of weeks have been a perfect example.

Previously I was using the satellite internet system IPStar as my main internet connection. Dial up using my land line was my first level backup. Dial up using my antique Motorola cell phone was my second level backup. That isn’t EDGE or even GPRS. It’s a modem program that runs on my PC and connects via USB 1.0 to my cell phone. It’s very limited but it works in a pinch.

So a couple of weeks ago my IPStar modem quit working. Apparently the LAN port died. When I went to my first level backup I found that the phone line was dead. Great. And then thinking about my second level backup, well the driver doesn’t install on Windows 7, so I would need to use my very old and in bad shape lap top. That’s when I went out and bought an air card, which has become my main interim internet connection (more later about that).

Now the story with my land line is sort of important because in the near future I should be able to get ADSL service and that phone line is critical. After a few calls to the very unresponsive TOT call center we contacted the local lineman and he check into it. Turns out the line had be chewed through by a squirrel. Lots of them around here and they like to run along the power lines so they can travel from tree to tree without becoming vulnerable to predators on the ground. Apparently they also like to chew on the wires. So after more than a week of no land line he got it fixed.

Two days later no dial tone again. We called the TOT office and learned that a truck had struck a pole on the highway and taken out a major trunk running to this area. So my land line was down again, for another week.

A week later, no dial tone again. I followed my wire from my house to where it connects to the main and I see that right at the junction box it is broken and laying on the ground. I bet the squirrel go it again. So as of right now I have my air card and no backup. And I’m thinking that having ADSL service isn’t going to do me much good because my land line will be down so often. This month was about 75% downtime.

My hope is that I get ADSL as primary and that I can get a reasonable uptime, with 3G as backup. ADSL is a prepaid monthly plan. The 3G air card is a pay as you go plan so it is a good backup solution.

I saw a short article on the website caleld International Medical Travel Journal which bills itself as “The World Leading Journal for the Medical Travel Sector”. That’s quite a claim. I always become a little skeptical when sites make those kind of claims while at the same time plastering Adsense ads on their site, but that’s another story.

This story says that the American Society of Anesthesiologists (ASA) has produced consumer guidance for American patients, urging them to ask the right questions when considering traveling internationally for surgery. Seems like a good idea. Let’s see if a hidden agenda becomes apparent, because so much of the stuff I have read by American doctors and health care professionals contains many attempts at spreading FUD (fear, uncertainty, and doubt) about seeking treatment overseas.

The first point in the guidance is to ask the question “Have I involved my local doctor in my decision-making?” That sounds like a good idea but in practice it likely fails to be useful. So often your local doctor knows little about international medical centers and you will hear comments about risks of treatment in “third world countries”. This kind of stuff comes from doctors who may not even have the same level of training as those “third world” doctors, or whose medical facilities don’t have the same level of certification. When I first traveled to Thailand I asked my doctor about health risks and immunizations needs. He gave me a crazy list of things I needed to do and vaccinations I should get. After living here for many years I now know he was clueless. I think he just gave me some list from the CDC, which is a pretty poor statement about the CDC’s awareness of health issues worldwide.

The rest of the list from the ASA seems pretty reasonable. Things like considering pre and post surgery care, contingencies if there are complications, and doing a good job of screening healt care provider credentials, all seem like obvious stuff but good to have in a list so they aren’t overlooked.

Ok, so do your due diligence, but if you ask your local doctor questions be sure to ask what his/her background and knowledge are regarding major hospitals in foreign countries because it might be a lot less than yours.