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What happens when a patient can’t afford the treatment you prescribe but is too embarrassed to say so? Health care executive Adam Cunningham joins the show to unpack the devastating ripple effects of medical debt, drawing on his KevinMD article, “The hidden toll of medical debt on patient health and survival,” and sharing how one friend lost her job, her insurance, and nearly her ability to function before finding affordable biologic treatment for rheumatoid arthritis overseas. You’ll hear why 16 percent of U.S. suicides have a contributing factor of medical debt, how patients weigh financial ruin against ending their lives, and what makes China’s tier one hospitals a surprisingly viable option for Americans priced out of care at home. Cunningham explains the accreditation systems that ensure quality abroad, the role patient advocates play in navigating costs, and the one question every physician should ask before assuming a patient will follow through on a treatment plan. If you’ve ever wondered whether medical tourism is legitimate or just risky, this episode offers a grounded, practical perspective you need to hear.
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Transcript
Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast. Today we welcome Adam Cunningham, health care executive. Today’s KevinMD article is “The hidden toll of medical debt on patient health and survival.” Adam, welcome to the show.
Adam Cunningham: Thank you very much for having me, Kevin. It is a pleasure to be on, and it is a pleasure to have sent my article to you as well.
Kevin Pho: All right, so tell us a little bit about yourself and what led you to write this article on KevinMD.
Adam Cunningham: Well, there are a variety of reasons. You could take the personal angle, or you could take the social angle. I have wanted to help people get into medicine ever since I was about four years old. I was a very sick child in Australia with asthma day in and day out, and I decided I wanted to be a doctor. I got to that point and realized that there is more to do, and I got very sick myself. So working inside of medicine was something quite difficult for me.
For instance, I have a friend in Maine in the U.S. She worked as a women’s advocate, lost her job due to recent budget cuts in the U.S., and simply was unable to afford a treatment for rheumatoid arthritis, which she developed quite aggressively to the point where she can barely function in day-to-day life. Coming from that, I decided that I think I can help these people. I have certainly enough training and experience to understand the issues. So how do I help?
What brought me to that is the realization that geopolitical and social perspectives on other countries and outside health care are shifting significantly. Places that we wouldn’t necessarily consider for getting treatment are all of a sudden viable destinations. If it is too expensive and you can’t afford treatment in your home country, then why would you settle for a lifetime of pain and suffering when you can get a comparable solution elsewhere? So that is where I am now.
Kevin Pho: All right. In your KevinMD article, you talk about the hidden toll of medical debt on patient health and survival, and you cite some pretty stark statistics that connect debt with higher mortality rates and suicides. Tell us more about that article and those statistics for those that didn’t get a chance to read it.
Adam Cunningham: Sure. Well, it is a pretty obvious conclusion that you have to come to if you are someone who comes into a whole bunch of medical debt. As a matter of fact, there is a great show about it, Breaking Bad. But it is quite simple. Say you are a family man or a family woman and you have got a whole bunch of medical debt. Say you have got cancer or something like that. All of a sudden you have got costs that are not just in the tens of thousands, but hundreds of thousands, and in some people’s cases, millions of dollars worth of treatment.
You have several options. You can burn through a lifetime of wealth that you have acquired and leave nothing for your spouse and leave nothing for your children. Or you can make another decision and simply end it all, whether it is through the pressure that is put upon you or whether it is through the desire or wish to improve the odds and chances for your family in the future. There is a whole host of reasons that can contribute to it. But charging hundreds of thousands of dollars for treatment that can be had elsewhere for thousands or tens of thousands of dollars is an absurdity that is going to result in people reaching for an option that should not be taken, especially in some of the richest countries in the world, and in particular the U.S.
Kevin Pho: One of the statistics that you cite was that 16 percent of suicides in the United States had a contributing factor of medical debt, right? You started off by sharing that story of your friend who couldn’t afford rheumatoid arthritis treatment in the United States and had to go abroad. Tell us about that journey of your friend.
Adam Cunningham: Well, as I said, she was a women’s advocate worker in Maine. She lost her job to budget cuts. It is a story that I think is quite familiar for a lot of Americans. As a result, she lost her health care insurance that was provided by her employer, which is a common story. The insurance companies, while she still had coverage, tried to give her the runaround for as long as possible and made things as difficult as possible. By the time she eventually lost her health care, she hadn’t received any real treatment. There had been no improvement of symptoms, and it has just been a struggle ever since.
So when it comes to how that applies to her, she was able to get biologic treatment in China. As a matter of fact, this is before I even started this business. I just simply helped her out, and we contacted a bunch of hospitals. Before you know it, she was getting biologic treatment in China for her rheumatoid arthritis. I won’t say that it has been a cost-free treatment process, but it has certainly been cheaper and quicker than had she tried to do it in the U.S. All up, it took us about four months to really get started on things. But now she is back to working. She is able to not just exist, but rather to go about her life in a relatively happy and healthy manner.
I think this is an option that exists for a lot of people in perhaps areas that they don’t necessarily consider. When you have limited options because of the financial burden that would be placed upon you, you don’t necessarily consider all those other things that need to get fixed up. All of those other things contribute to quality of life. People who have things such as TMJ issues, as an example, might leave it for 10 or 20 years simply because of the cost of getting treatment. Quite often, surgery is something that they just don’t want to consider, so they suffer with it. But when that fix could be had for a relatively small amount of money in overseas countries, who wouldn’t want to do that?
Kevin Pho: Now I always hear horror stories in the media about patients going abroad or to other countries where the care isn’t quite the same as it is in the United States, and then they have bad outcomes because of that. How does one guard against some of those risks of going abroad, and how do they know that the care they are getting could be comparable to the care they are getting in the United States?
Adam Cunningham: I won’t necessarily speak to other countries such as Thailand or Mexico. They are not my area of specialty. However, I can speak quite intensively as to the situation in China. I recently published a blog article on our website regarding the quality of health care and hospitals in China. It is an incredibly intensive process for accreditation and quality control in China, in particular compared to a lot of other countries, even the U.S.
Of course, there are going to be issues with various hospitals everywhere. If you go to some of the premier hospitals in New York, they are going to be significantly better than going out somewhere in the middle of Arkansas. The same goes for everywhere else, such as China. So we locate a lot of our partnered and associated hospitals in the tier-one cities in China, and they all have what is called 3A accreditation and certification. In China, there are about 35,000 different hospitals, and of those 35,000, about 1,600 have 3A accreditation. This is a government quality assurance accreditation that essentially proves that they are at the very peak of medical quality, whether it is in the cleanliness of their hospitals, the qualifications of their staff, or the outcomes of their patients. 3A pretty much is the top of the board. On top of that, you have got your international accreditations such as the JCI or Joint Commission International, which accredits hospitals, and there are about 50 of those in China right now. All the hospitals and clinics that we are partnered with currently are JCI accredited hospitals, which is really the international standard.
Kevin Pho: So in terms of other treatments and procedures, you mentioned this case with biologics for rheumatoid arthritis. What other common areas are people going to China for because of high costs in the United States?
Adam Cunningham: Well, it is not something that I necessarily believe to be the best choice, but I have seen a lot of recent TikToks and Instagram reels about people going to China for MRIs by comparison to the U.S. They talk about how they can go to China, specifically Shanghai, and get an MRI for 72 dollars or something like that. While that is true, I wouldn’t necessarily recommend it. There are a lot of places in the U.S. that do offer quite reasonable treatment. They are just difficult to find.
When it comes to China, pretty much anything and everything you could possibly want to do is available. There are a lot of experimental cancer treatments there, as well as a lot of stem cell treatments. IVF is one of the biggest ones, in particular because of the one-child policy that they have had, and the knock-on effects of that. A lot of people are into IVF, so there is a massive industry built around it. Not just a massive industry in terms of quantity, but as a result of that quantity, the practitioners there have frankly perhaps more experience than anyone else in the world. I have spoken to doctors who have literally done tens of thousands of IVF procedures. That is not necessarily the volume or experience you would expect in other places.
Then you have got plenty of other things such as traditional Chinese medicine, a lot of acupuncture, and a lot of massage that is integrated into medical treatment. When people go in for a hip replacement, a lot of hospitals, in particular private ones in China, also have traditional Chinese medicine incorporated into their services. In addition to that, a lot of specialist treatments that, at least in Australia, you might have to go to Germany or the U.S. for, are quite often available in China to one degree or another. I think that is the strength of things. You don’t necessarily have to go to Germany or a particularly overworked clinic or hospital in the U.S. when you can go to China and not face a wait time of six to eight weeks or three to four months. If you want to go in and get treatment, it is just a matter of how quickly you can get there. So I would frankly say anything and everything that you could possibly want to do medically speaking, you can do it in China.
Kevin Pho: So what happens if there are longer-term complications from whatever medicine and treatment a patient has in China and they come back to the United States? Talk to us a little bit about some of the follow-up and potential complications that could arise.
Adam Cunningham: Well, as I am sure you are quite well aware, pretty much any surgery or anything that involves some kind of incision in the skin is liable at some point or another to create some form of infection or lead to some form of infection. Most hospitals that we work with in China are quite aggressive when it comes to making sure that these things don’t happen. Having been around plenty of hospitals in my life, I would say some of these are the most aggressive hospitals when it comes to making sure of the cleanliness and the very high standards of medical practice.
To answer your question fully, they quite often suggest a waiting time of two weeks or so when visiting China for surgical treatments. That is just a period in which you basically stick around. You don’t necessarily have to be in the hospital. You can be at a hotel or something like that where you can be monitored and assessed, and then they can give you the all-clear to go back home. On top of that, all of the reports, all of the imaging, and pretty much anything that could be written down is then passed on to your doctor or to your medical team in the U.S. As long as your doctor in the U.S. agrees to it, all of the information regarding your treatment in China can be easily passed on and then can be monitored and supported from there. So it is really not a complicated issue, I don’t think.
Kevin Pho: If a patient is in a similar situation to your friend and considering going to China or another country for lower-cost treatment, tell us the type of questions they need to ask themselves and the type of questions they need to ask whomever is arranging this to make sure that is the right option for them.
Adam Cunningham: Of course. In the end, I run a business where we refer people to Chinese health care. However, regardless of my own wants, wishes, and desires, I think the most important thing that people need to ask themselves is: “Can I get it at home? Can I get what I want at home for a reasonable price?” While I will say yes, there are very affordable quality procedures available in China, there are also very affordable quality procedures available in the U.S. It is just a question of looking in the right places.
One of the first things I would say is to speak with an advocate. Patient advocates are probably the most important resource for anyone who is undergoing some kind of surgical treatment or medical treatment. In effect, their responsibility is to help you. The hospital’s responsibility is not necessarily to help you, but to make money out of you. By employing or consulting with a patient advocate, you are able to cross out both of those effects to some degree and reach a happy midpoint. So that would be the first step that I would take if I were a patient.
From there, I would start looking abroad. As I am sure you know, there are quite a few good medical tourism opportunities. However, from my experience and my study, and of course I have to say this, I believe China to be frankly the best combination of quality and price. While there are cheaper options, like India or the Philippines for instance, when it comes to the quality that you would expect from tier-one hospitals in the U.S., that is the same quality that tier-one providers in China will provide, however, without the cost.
Kevin Pho: As a primary care physician here in the United States, tell me the type of questions I should be asking patients to make sure that all the other United States options from a cost standpoint are fully explored before patients consider something abroad. What are the type of questions I can ask in the exam room?
Adam Cunningham: Probably the first question that I think you could ask a patient is whether they have spoken to another doctor. Have you got a second opinion? I am sure that is a question you have had to ask many times, but most people overlook it. I certainly know that many practitioners overlook it, but I think that is the most important thing to consider: Have you tried to get a second opinion on this? You don’t just get a second opinion by going to another doctor; the facility itself can provide other options. Consulting advocates, for instance, provides other options.
On top of that, the other question that I think would be best to ask would be: “What is your financial situation?” I think that is perhaps one of the most important things to consider as a practitioner. I certainly was taught that you don’t just have to attack the presentation itself, but you also need to understand the patient and the particular circumstances that they are living under. If a patient is prescribed a certain drug and they can’t afford it, they might not necessarily tell you. It is something that could very well embarrass a patient to say that they can’t afford it. I certainly know in my experience that I have seen patients who will say they will get a drug, but when we verify with a hospital pharmacy, there is no record of them doing it. You won’t necessarily know these things unless you go above and beyond as a practitioner and investigate it. Is my patient actually taking this drug? Is my patient actually following up on treatment? I think the most important thing to ask is if your patient can afford this treatment.
Kevin Pho: We are talking to Adam Cunningham. He is a health care executive. Today’s KevinMD article is “The hidden toll of medical debt on patient health and survival.” Adam, let’s end with some take-home messages that you want to leave with the KevinMD audience.
Adam Cunningham: My take-home message, I think to reiterate, is that as a practitioner, one of the most important things you can do is to understand if your patient can afford the treatments that you suggest. You need to understand if your patient can afford the care that you suggest, whether it is investigations or treatments. As a patient, I think the most important thing that you can do is to explore options, whether those options be second opinions, patient advocates, or treatment abroad. For both parties, I think the most important thing to do is to fully understand the situation, to collect and collate as much information as possible, and then to make a decision with that information.
Kevin Pho: Adam, thank you so much for sharing your perspective and insight. Thanks again for coming on the show.
Adam Cunningham: A pleasure, Kevin. Have a good day.
