herniation diagram

One of the things I like most about India is it's medical system. As an American, I've experienced both the Indian and US medical systems, and at this point I have a very strong preference for the Indian one. Somewhat surprisingly, the Indian medical system is based on free market capitalism, and as a result it tends to provide a much better experience than the US system.

A lot of folks have asked about my experiences, so I decided to write this up.

About me: I'm not Indian, I speak little Marathi, and in general I stick out like a very tall fair and lovely advertisement over here. In short, I'm not a local. That said, I'm familiar with India - I know when an auto driver is ripping me off and I negotiate better than many Indians.

At the time of these experiences, 1USD = 60 INR.

As a counterpoint to my experiences, I recommend reading an article about spine surgery in the NY Times. As my American readers know, it's very difficult to get a price estimate before having medical work done. Billing errors are quite common - the article I just linked to describes a $117,000 discrepancy between an estimated and final bill.

How it all started

Sometime last year I started having quite a bit of pain in my back and leg. It started off when I did unilateral exercises; one leg squats and one hand pushups got quite uncomfortable. I also felt a bit of pain in the mornings. This is an issue that arises for me - perils of being very tall.

To start with I adjusted my lifestyle - no unilateral exercises, no running, no flexion exercises, more stabilization (e.g. planks).

Over time the problem progressed to the point that I was unable to sit through lunch. At some point I took a lovely Mozambiquan lady to dinner and I had to stand up twice just to relieve the pain. Standing up or lying down was fine - sitting was the only issue.

To start off, I made an appointment with Rajesh Parasnis at Oyster and Pearl Clinic. The experience was quite straightforward. I called up, requested an appointment, and asked the price. I was told over the phone that visiting the doctor would cost me 400rs - about $6.50. Insurance or a lack thereof was not an issue - this was a very simple fee for service arrangement.

(You can interpret this name-drop as an explicit endorsement. In the event you need spine work done I highly recommend this guy.)

After the visit we went through all the basics; rest, physical therapy, anti-inflammatories. None of these things cured my pain, but overall the experience was very straightforward. I asked for work to be done, and I asked the price. I was given the price. I handed over rupees, and got the work done.

So far, no billing errors, no paperwork - in terms of logistical difficulties it was

It didn't get better

In spite of our best efforts, things got worse. In spite of the rest and pills, things progressed to the point that I was unable to sit at all. The next step in treatment was a Selective Nerve Root Block - an injection of cortisone into the disk and nerve area. The goal is to reduce the swelling of the disk and lower the pressure.

As always, I was told the price (10,000rs or $160) before the procedure. I scheduled the procedure for the next day and made a quick trip to the ATM. On the day of the injection things were pretty simple. As before there was no paperwork - just show my receipt and wait for the doctor to arrive. The hospital was clean and modern - more or less exactly what you'd expect in the US. The only noticeable difference difference is that in the US, only the doctors would be Indian.

I didn't feel great after the injection, but the pain substantially decreased the next day. Overall, things were looking good. I felt no pain, I resumed exercise, things seemed to be moving well.

Coming to America

My sister was getting married, and as a result I flew back to the US to attend. Unfortunately, sometime after the wedding, the problem came back and worse than before. I knew I needed some help, so I attempted to get medical treatment in the US. This was easier said than done.

Most doctors refused to even give me an appointment; I overheard one talking with the receptionist, and he told her I was probably seeking drugs. I've never heard of recreational cortisone use, but I guess that's a real thing? A couple of receptionists said the doctor might do it, but they were unable to tell me the price - they could however tell me that even talking to the doctor would cost $200. For the most part no one would talk to me without insurance.

I attempted to sign up for Obamacare but failed. I was able to get a price quote - $350/month.

After weeks of effort, I found a doctor in distant Brooklyn who was willing to take cash and would give me a price quote on the cortizone injection. I painfully took an Uber and waited for half a day in the office. The facility, combined with the entirely Russian staff, gave me the impression of a shabby Soviet facility. It was cramped, the equipment was old, but it didn't seem to lack anything important. Before service I was required to pee into a cup and answer a variety of questions about whether I've ever sold prescription drugs, faked symptoms, or abused narcotics.

I was getting nervous that I'd be rejected again, but I got pretty lucky. The Russian lady doctor had a very direct bedside manner and unlike many others, she actually paid attention to what I was asking for. Unlike most of the other US doctors she paid close attention to what I wanted and realized that I wasn't asking her to inject anti-inflammatories into my spine for recreational purposes. The injection improved my situation, but my problem was far from solved.

After a partial recovery I paid $500 extra for a direct flight with exit row seats. I survived takeoff and landing via illegally obtained Xanax, and stood up for the bulk of the 14 hour flight.

The surgery

Once I returned to India, things went smoothly. I visited the doctor immediately after arriving and he concluded that I needed surgery - a micro-lumbar discectomy. The procedure was tentatively scheduled a few days afterwards and I was requested to get another MRI to confirm. (Depending on the outcome of the MRI, it was possible the surgery could be cancelled.) As is the Indian custom I was told the price of the MRI (7,000rs) prior to receiving service.

I was also told the price of the surgery up front - 1.4 lakh only, or approximately $2,000. I was also told I might spend a few thousand more on incidental medications after I exit the hospital. I handed over my credit card and prepped for surgery.

prepped

I'm quite happy in this picture - I'm on a lot of drugs. I don't normally have such a crazy beard, but at this point it had been about 2 months since I was able to sit down long enough for a haircut.

After I got out of surgery I wasn't nearly so happy. There were no painkillers, I was desperately thirsty and forbidden from drinking anything for several hours. But the pain in my back was gone.

Unlike a US hospital (or so I'm told), they were in no rush to get me out the door. Economically this was a bit surprising - I paid a flat fee for the surgery, hospital visit, and everything else - so they were not making any money by keeping me in there an extra day. I stayed in for 4 days afterwards, and even the (very bad) food was included in the price. They wanted me to stay a fifth day, but I was desperate to get out.

The hospital was also very accomodating of visitors - my girlfriend stayed with me throughout the entire process. I had a private room and no one objected to her camping out there with me. The staff were certainly a bit curious - most foreign patients are middle eastern so an American showing up with an African girlfriend is a bit unusual. But overall, with the exception of one nurse that I strongly disliked, the experience was as good as major spine surgery could possibly be.

Here's the final bill.

prepped

I didn't take a great picture. But the total cost of the surgery was 1.4 lakh only. Unlike what one expects in the US, there were no billing errors, discrepancies, or extra charges. I paid another 2000rs or so for post-hospital medication and 500rs for a back brace (as they told me I would). The total cost was within 2% of the price quote I was given.

The aftermath

After surgery the recovery was pretty straightforward. The original problem manifested as an inability to sit down. This is me a week after I was discharged from the hospital, enjoying brunch in a comfortable sitting position.

prepped

It's now a year later and I've had no further problems with my back. I've certainly had to adjust my lifestyle - I've substituted one leg squats for deadlifts and will probably have chicken legs forever. I've mostly stopped lifting weights, and focus on bodyweight equivalents - inverted shrugs rather than weighted shrugs, levers rather than dumbell rows, and Hindu pushups rather than the military press. I haven't boxed since the surgery. (For anyone who either lacks a gym or who has similar injuries, check out Beast Skills, Al Kavadlo and /r/bodyweightfitness. As an added benefit you can often workout outdoors rather than some smelly basement weight room.)

Overall, I'm completely satisfied. The Indian medical system provides fantastic care. It differs a bit from care in the west in that it far more heavily emphasizes rest and hospital care - "quicker and sicker" is not something Indian hospitals do. But regardless of the costs and difficulties in getting care in the US, I still found Indian care to be more or less equivalent.

On the cost side, the capitalist underpinnings of the system combined with obsessive cost consciousness of the average Indian has resulted in low and transparent costs to the customer. The costs aren't just low by American standards - they are low even relative to Indian wages. In the US, the billing error on a surgery like this might be approximately 1 year of salary for a typical programmer (say, $150k salary compared to a $117k billing error) and about 2x GDP/capita. In India the total price of 1.4 lac is 0.5-3x a typical programmers salary (0.5 lac - 5 lac) and about 1x GDP/capita.

On net I highly recommend medical tourism as a way to get care. It's certainly how I'll get anything besides emergency work done.


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