Single Payer, Medicare For All, Universal Healthcare – as these phrases get tossed around the presidential debate stage we get real with Suzanne Garber, whose documentary film, “Gauze: Unraveling Global Healthcare” compares and contrasts healthcare systems around the world to determine what “best healthcare” means and what it really looks like.  We talk with Suzanne about her own experience with medical care both in the US and abroad, what she discovered during the making of “Gauze” and why many Americans are choosing to go overseas for affordable, quality care.  Tune in for a lively conversation with this filmmaker who traveled to 24 countries and 174 hospitals in search of the best healthcare systems around the world.

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Filmmaker Suzanne Garber_Gauze: Unraveling Global Healthcare

 

Website for the film: “Gauze: Unraveling Global Healthcare”
Gauze (company) database of international hospitals: Gauze
Two companies that list healthcare costs: Castlight Health and MediBid

Additional links referenced in the interview:

INTERVIEW TRANSCRIPT:

JANA  – It’s Halloween in America, and one of the scariest things I can imagine is being at the mercy of the roulette wheel known as US healthcare. Let’s face it, unless your name is Bill Gates, we’re all just one major illness away from financial ruin. That’s the major takeaway of a new study from the American Journal of Public Health, which found that medical problems contributed to 67% of all bankruptcies in the United States.  Quality of care in the United States also varies, and access can be difficult. There must be a better way.

JANA  – How does healthcare work in other countries? That’s a question Suzanne Garber set out to answer in her documentary film “Gauze: Unraveling Global Healthcare.”  For the film, Suzanne traveled to 24 countries and 174 hospitals in search of the best healthcare systems around the world. Filmmaker and author Suzanne Garber is a longtime advocate for increased access to quality care. She’s been featured in The New York Times, USA Today, US News and World Report and elsewhere. And she’s spoken at dozens of international conferences. But today she’s here to talk with us about our first film, the documentary, “Gauze.” Suzanne, welcome to The Agewyz Podcast.

SUZANNE  – Thanks so much for having me.

JANA  – Well, if anyone is well-suited to sorting through healthcare systems around the world, it’s you. I would love for listeners to learn a little bit about your upbringing.  Tell us about it.

SUZANNE  – Sure. I had a very international upbringing myself, actually. My parents were expatriates to other countries. And what that means is, my father’s job, he was a corporate executive for General Electric, large multinational, caused him to live mostly in the Middle East and in Africa as well as Latin America. And of course, as a young child, I had to accompany them. So I grew up in Spain, Egypt, Algeria, Dominican Republic, Mexico, England and about eight states. And that really gave me a great perspective on, certainly global travel, and then also healthcare. Because even as a child, I had to go to the hospital, and I have been hospitalized probably in more countries than people have even visited as a tourist.

JANA  – So I know that your professional background involved traveling the world and credentialing, various hospitals. So you spent a lot of time in other countries as an adult. And of course, as you mentioned, you’ve gotten sick in other countries. So in the film, you said you got sick in “in a very serious way.”  And you wait until you got home to get treatment, which was quite common, as you pointed out in the film.  So what happened in that particular situation and where were you?

SUZANNE  – Yeah, so the year was actually 2013. I was in the Middle East. And my job at the time actually was to credential hospitals. So I knew very much about the quality, the sanitation, the hygiene, the profile of different hospitals, and I had just come out of a meeting with a hospital CEO, where we had walked into a room and he was very excited to show me the latest acquisition of new medical equipment and wanted to demonstrate on me, how to use it. And I said No, you know, I, I know how these things work. You don’t have to demonstrate it.  But he wanted to show me. And it was basically an endoscope.  And he popped it into his mouth, and up came his mouth on this huge video screen in the room.

SUZANNE  – And I was looking and thinking, this is unorthodox. I see that he’s very excited about this but, um, he didn’t sanitize it before he put it in his mouth. And I’m thinking well, I I’m guessing they have good cleanliness standards here because I’m sure hoping somebody sanitized it. Well, he didn’t sanitize it after he put it back in the holster. And we walked out. And there was nobody else there with us. So the next person who goes to have it put it in their mouth, I certainly hope the nurse or the attending person would clean it, but I don’t know that to be the case.  And since this is coming from the CEO, you know, my thought is, Wow, well, maybe some of the practices do trickle down. And I couldn’t really be assured of the cleanliness, quality in that particular facility.

SUZANNE  – That’s what caused me to think I’m not getting sick here. I do not trust the quality here. Even though they may have won a lot of awards, they may have a number of fantastic citations and commendations, I’m not getting sick here. And basically, I was just feeling very tired, I was having some difficulty swallowing, and I thought – it’s not really that big of a deal.

SUZANNE  – But then when I came back to the US, I was misdiagnosed for about five months and had gotten some recommendations on procedures that probably would have killed me, looking back. And ultimately what it was determined was that I had a congenital heart defect, which means that I’d been misdiagnosed my entire life.

JANA  – Oh, wow.

SUZANNE  – Entire life.  And I needed an open heart surgery to correct this defect. And that’s really what got me thinking, while I was in the hospital, where is the best care? And furthermore, actually, how do we define best in healthcare? Because it’s not really a topic that we discuss a lot. I mean, you and I could talk about the best cup of coffee. I had the best night’s sleep last night.  You might tell me about the best massage you had. But you know, we don’t really sit here and talk about you know, I had the best colonoscopy!  Hey, that mammogram I had, what an expert mammogram person there.  We don’t really talk about healthcare in terms of “best.”  We actually just tolerate whatever happens, and we accept whatever happens without actually giving critical thought to what’s occurring to us and what we actually need.

JANA  – Yeah, and that hospital that you were at, where was that?

SUZANNE  – I am not going to say the country.

JANA  – Okay.

SUZANNE  – But I will just say that it was outside of the United States. But again, like I said, you know, when I came back to the US, I was misdiagnosed here in the US for five months, and ultimately my entire life.

JANA  – And this was not the major health scare that you had just six weeks after you got married, which was different, right?

SUZANNE  – Yeah, I’ve got quite the medical history, actually. Six weeks after we got married, I had been experiencing some discomfort in my abdomen area.  I wasn’t really sure what was going on. I had some, you know, very vague and innocuous symptoms that could have been almost anything, honestly. And when I went to my primary care, she informed me that I had a large abdominal mass that needed an immediate ultrasound. And turned out I had ovarian cancer, which, at the age of 33, was a complete anomaly, and quite the surprise.

SUZANNE  – I’m very, very blessed and very fortunate to have found that so quickly, but I think part of that, too, was that I know my body pretty well and I knew that there was something wrong, and I take a great personal responsibility for my own care. And then of course, once the diagnosis came, then my husband took a great personal responsibility and I think we show it in the film, of him really bird-dogging and championing for me, which is what I know you and your organization also advocate for, is having an advocate and a champion to run you through and to coach you through this very complex maze that is known as American healthcare.

JANA  – And as a person who on your own is quite capable of that, there’s nothing like having the support of someone to help you through that, because you’re so overwhelmed by the diagnosis to begin with, right?

SUZANNE  – Oh, sure. Especially when you’re younger. You know, I teach at a university and we talk about healthcare a lot. We also, in my company we have a lot of college interns who never give a thought, not even a second thought – they don’t give a first thought to healthcare.  Because they’re young, they’re likely not going to experience something tremendously impactful in their life. So you know, having somebody that can help you, regardless of your age, whether you are very young or you are very old. You do need somebody to help me through that for sure.

JANA  – Oh, yeah. So there was a turning point for you in terms of thinking about the cost of care, for you personally, and you go into this in the film.  I wonder if you could share that?

SUZANNE  – Totally, totally. You know, it’s interesting because I’m actually gonna even back up a little bit, basically to say, I’m going to give a little bit of a peek into the film so we really come away with, in terms of defining “best” in healthcare.  Because if I could ask, you know, 10 different people, I would probably get 10 different responses on what healthcare means. And I know there’s been a number of studies, whether it’s by the Commonwealth Fund or Johns Hopkins or other think tanks that look at what patients want in terms of health care. And some people might say a quality outcome.  Or that I lived.  Or that, you know, that I’m no longer sick. Some people would actually say that the nurses are nice, or the doctor listens.  Or free parking.  Free parking is actually a big deal in some urban areas.

JANA  – Yeah, right.  Sure.

SUZANNE  – But it goes into like the whole patient experience and satisfaction. And so really what we came away with, the three overarching themes of our film are: quality, affordability and accessibility.  They’re the three primary components that go into making up what most people think of as quality healthcare. And certainly, cost is a major, major implication.

SUZANNE  – And so for years, I’d been employed by large organizations that had amazing health care benefits. And I found myself in a position where I no longer had amazing healthcare benefits. And that got me to thinking, Wow, I never thought about how much healthcare costs, because I never was really responsible for that cost in the first place. Maybe a co-pay here and there, but I never really had to worry about it. And once I had that experience, I had to then start looking at and even making decisions on whether I would seek healthcare based upon the cost.

SUZANNE  – So if I could even compare this to grocery shopping, you know, am I going to go for the name brand?  Or am I going to go for the store brand?  And in healthcare, we don’t – as consumers – really have that option, because at least in the United States – and I can certainly tell you about a number of countries where they’re extremely transparent with their pricing – we don’t have transparent pricing here. And partly, that’s because of the system that we have set up, that is mostly an employer-based system, because that’s who’s predominantly buying insurance plans, as opposed to a consumer-based plan, which, ironically, the consumers are ultimately the ones purchasing the actual healthcare.  But employers are the ones that are purchasing the health insurance.  So it’s not really a congruent system that we would see in other countries.

SUZANNE  – And so for me now being on that total consumer side of being a total consumer, meaning that I’m buying both the healthcare, I’m also buying the healthcare coverage. That was very illuminating to me. And now, certainly as a college professor and seeing how, especially students and younger people from this date moving forward, are really into a gig economy. We see that with Uber, we see that with Lyft, and with Airbnb, and so many people taking on more consulting roles and gigs, and also knowing, too, that the younger generation – I mean, it’s just a fact – they do not stay with employers for very long periods of time. And it’s certainly one of the overarching themes of American economics that employer benefits are not as much a draw for the younger generation.

SUZANNE  – And so we must change our healthcare system to really take into account the changing needs of the American workforce as well. And that means being fully transparent in healthcare, with the pricing, with the quality, with the accessibility as well.

JANA  – So Suzanne, how does the US rank in terms of best healthcare compared to other countries in the world?

SUZANNE  – Well, according to the World Health Organization, we are ranked 37.  So there’s quite a few countries that do better than us in that aspect.  But from a life expectancy standpoint, you might be shocked to learn that we’re ranked number 43 in the world.  And it’s interesting that Japan is always ranked in the top 10. And they’re ranked number two in terms of life expectancy.

SUZANNE  – So if we look at countries like Japan, Iceland is always ranked very highly, Singapore is also ranked very highly, they also outdo us in areas like education, as well as in different food production and nutrition. So the US is actually – I don’t know if we’re necessarily falling farther behind, but we’re not as high as we think we are in many categories.

JANA  – Mm-hmm.  You interviewed Marty Makary, who has this great book, “The Price We Pay,” and, you know, he makes the point that people want to know what they’re getting for their money. But you really wisely included this other guy, Steve Kelly, who says, Well, you know, publishing the prices doesn’t really help me as a consumer because we know the prices have no relationship to the cost. Why is this? This issue of transparency is kind of a hot topic right now, but I’m not sure that it’s really put in the right context or understood as broadly as perhaps it could be.

SUZANNE  – Yeah, actually in June, I think it was June or July, President Trump actually signed an executive order that mandates that all US hospitals must publish list prices for their procedures. And it kind of goes back to what Steve Kelly who’s the CEO of ELAP Services was actually speaking about. And it’s this: yes, we can publish prices, but what it actually means nobody really knows. Because as you said, it doesn’t really relate back to the cost. And so if I were to – you know, I’ll use a food example because everybody eats – so if I were to talk about, with a grocery store, we can compare, literally, we can compare apples and oranges. Apples might be $2.99 a pound, and you might get oranges, you know, three for a dollar.  Actually three for a dollar is pretty cheap.  We’ll say three for $3.00. Anyway, but you have an idea of like what that is.  But I could go to different grocery stores and I could compare. Okay, maybe somebody’s $2.49 a pound on the apples, or $3.99 a pound on the apples, and I could also compare the organic apples with the different varieties of apples. Whether it’s Gala, or Red Delicious or whatever, Granny Smith.  With healthcare, we don’t have that option.

SUZANNE  – And there’s a couple of different companies that are trying to make healthcare more transparent. And what they do is they will call up different doctors’ offices and ask for list prices, if they can get them. And they will publish those on their websites. What they do is they will show the swing in prices. So let’s just take a knee replacement. They will call up different providers, ask for the cost, and they have seen swings from $12,000, all the way up to say $40,000.  Why?

JANA  – Wow.  Yeah – right.

SUZANNE  – And I don’t have an answer to that, other than it’s what the provider chooses to charge. Now, again – because our health system is so complex that there are a number of caveats in that, because when you say list price, what does that actually mean? And who’s actually paying for that? So with this example of $14,000 to $40,000, maybe the $40,000 is pre-discount, and that’s pre-discount before Aetna, Cigna, United Healthcare, Humana, whoever gets a hold of it.  Maybe the $14,000 charge is the Medicaid or the Medicare charge. So it really just depends. And unless you know the actual vocabulary and vernacular to ask and to speak, you won’t get what you’re really looking for, which is hopefully the best deal for you.

SUZANNE  – I actually open up the film with such an example, of me going for a colonoscopy.  I’m at that age where I need to get preventative care, and I do encourage – the best healthcare really is preventative health care. And so I was getting a colonoscopy, I had gone to see this particular provider a couple times before, I had made sure with the staff that they took my insurance and that, you know, I would just have to pay the co-pay. Well imagine my surprise when several months later, not even a couple of weeks, but several months later, I received a bill for over $13,000 for a colonoscopy.  And no lie, the colonoscopy was on April 1st.  And I thought, Is this some kind of a joke?

SUZANNE  – And when I called up and I talked to them, and I said, Look, I had verified this with you twice before and had two previous visits. I don’t understand why I’m being charged this amount. And I said, you realize you’re three times what the national average should be for this. And the response that I got was, Well, not everybody pays this. In fact, very few people pay this price. I’m like, Yes, but you’re asking me to, and I’m not going to. And so we had a conversation about why this occurred, how this occurred, how this could be ameliorated, and what recourse I as a consumer had.  Because again, I had gone through what I thought were all the proper steps and, as you rightly pointed out, upwards of 67% – two thirds of all personal bankruptcies in this country, are because of medical decisions or medical procedures. So yeah, so cost really does play a huge factor into the lives of every single American, whether you’re covered under an employer plan or not.

JANA  – And I thought it was great how you took us through the process of how it unfolded before and after the procedure. You said in the end, or they said, I guess, If you don’t sign the form, you don’t get the service. So you really were at the mercy of the person behind that glass pane in your waiting room, when you went for your procedure, even though you had done all this homework in advance to ensure that, you know, you would only be paying a certain amount.

SUZANNE  – Yeah, but you know, what’s amazing to me is, and I encourage all your listeners to really read through that form that every healthcare provider makes you sign.  And what they make you sign is a form that mandates you have full responsibility for the charges. I know very few people who actually ask what those charges are. I do as a matter of routine and a matter of principle. Well, what are those charges?  Because I want to know. And invariably, I would say 9 times out of 10, the person behind the glass pane, doesn’t know.

JANA  – They don’t know.  Yeah.

SUZANNE  – And so that will then set me off on a wild goose chase as, Well, I need to know, so you need to be informed, and you need to get me that information. My mother went in for a surgery about three years ago, it was to remove a hernia. It’s not a life-threatening surgery, but it had some implications for her. And she knows how I am.  She asked me to be her caretaker. And before she was wheeled back, I, of course, went up to the glass pane and said, Hey, I’d like to know how much these charges are. And – because I wasn’t going to have her sign the form – and you know, my mom was like, you know, please don’t cause a scene. I didn’t cause a scene. But, because she wanted to have the surgery done, because they were saying, well, we can’t wheel her back until she signs the form. And I said, Well, we’re not signing the form until we know what the charges are.

SUZANNE  – Long story short, it took them two and a half hours to figure out h`ow much this hernia operation would cost. And I ended up going back into the back room of, like, the billing department to meet with the billing manager who pulled out all of these archaic 3-ring binders.  And she started adding up the cost of the anesthesiologist, and the operating room and the stitches and blah, blah, blah, blah, blah. And ultimately, she came up with this number, which she basically kind of wet her finger, put it up in the air and said, I think this might be right. And came up with some number of about $54,000.

JANA  – Wow.

SUZANNE  – Right?  So my eyes got kind of big.  I was like, Wow.  Then of course, I made sure you know, my mom is obviously of a Medicare age, so I just made sure, even though she had done all of that with her doctor, I just wanted to make sure as well.  Because I certainly didn’t need her to go through that additional pain of seeing a $54,000 bill in the mail a couple months later. So yeah, it’s important to do your homework. It’s important to be informed. And it is very important to speak up when you think something’s not right.

JANA  – So tell us about this fellow Robert Novrotski, who is a really great example that you give in the film of a patient who traveled – who’s been traveling to Thailand for treatment for 20 years. And Thailand is portrayed as one of the successful healthcare systems around the world.

SUZANNE  – Yes. So we, as you mentioned, we visited 174 hospitals in 24 different countries.  And in each hospital we asked about the patient population: what percentage of patients were local, what percentage of patients were foreigners. And so when we went to Thailand, we visited a number of hospitals there, and one of the hospitals we visited was Bumrungrad, which is one of the top hospitals in the world and certainly for medical tourism.  They’ve actually kind of staked a claim in the medical tourism realm. And as you mentioned, I’ve spoken at a couple of conferences, I met their CEO Mack Banner before – former CEO, he’s retired now. We were given a great tour of their facilities. And we had asked if we would be able to interview a patient. And they readily handed us a number of patients that were willing to extol the virtues of, not just that particular hospital, but just the entire system as a whole.

SUZANNE  – And so we came across this man from Pittsburgh, he was of a Medicare age as well. And when he started doing the financial implications of certain procedures in the US, even with his Medicare coverage, it was going to be cheaper for him to travel outside of the United States, stay a couple of weeks during the recovery, and then come home.  It would still be cheaper than just the actual procedural costs of his co-pay here in the United States.  And from what he said, the care was exemplary.

SUZANNE  – And I have many friends and many relatives who are in healthcare, and I certainly do not, at any point, mean to indicate that healthcare providers in the US are less than conscientious, and are less than giving of their full endeavor to their patients.  But I will say, there’s different cost structures in different countries.  And for Thailand, they had a higher nurse to patient ratio than they do here. They also have different implications in terms of like their electronic health reporting, and medical records, whereas a great percentage of physicians’ time, as well as nurses, is filling out forms.  Whereas in Thailand, they don’t have necessarily the same legal constraints. There’s certainly still a great emphasis placed on the electronic medical records, but it’s not to the detriment of the patient. And so you’ll find a greater ratio of nurse to patient, and even doctor to patient.

SUZANNE  – So from his perspective, and we actually interviewed quite a number of international patients, we just found a higher level of satisfaction. Particularly with that provider to patient ratio. And they also felt that because there was a greater level of, or propensity of people around them, they felt that they were getting heard. They felt that their needs were being addressed more readily and more quickly, they felt that their response time was much more accurate. And they just felt like they had a better handle, themselves, when they left the hospital on what they should be looking out for, of potential hazards that might befall them, for instance.

SUZANNE  – I will say, however, on the medical tourism front, that they also felt that when they came back to the United States, if they did have an issue, that their providers here – healthcare providers in the United States – were not as willing to treat them. So that is somewhat of a detriment to medical tourism. It also doesn’t necessarily foster collaboration amongst healthcare providers, because some providers are thinking, Well, why would I want to clean up a mistake that somebody else made?  And so that can sometimes be a concern. I didn’t find that to be a huge detriment or a huge issue that people were getting care abroad and then having issues, you know, months later, but obviously, with an older population, you’re going to be running into some kind of complication at some point, just simply because of age.

JANA  – Mm-hmm.  How popular is medical tourism? And maybe you could define that for listeners who aren’t familiar with it.

SUZANNE  – It’s a great question, actually, because there’s a number of different definitions to medical tourism, itself. And also the numbers widely vary.  Medical tourism is basically going outside of your home area to find appropriate treatment for you. Some people define it as 100 miles. Some people define it as another state. Some people define it as crossing borders. So it really depends. It can get quite murky. So if I’m talking about traveling from, you know, 100 miles, that could possibly be somebody in – I don’t know Pittsburgh, Pennsylvania, going to Baltimore to Johns Hopkins.  So that might be considered medical tourism.  Or somebody going to the Mayo Clinic that doesn’t normally live in Minnesota, for instance.

SUZANNE  – But it could also be somebody going to Mexico for bariatric surgery, or it could be somebody going to Cartagena, Columbia for heart stents, for instance. So depending upon how you define it, that can have implications for how widely ascribed it is. Again, there’s wildly different numbers. I’ve heard anywhere from 700,000 to 7 million Americans seeking medical treatment outside of their home area. So again, it fluctuates wildly, but basically, it’s with the notion that someone is taking proactive care of their health, and either not encountering the quality, the affordability or the accessibility in their home area, and going outside of their home area to find that.  And that could actually be Canadians coming to the United States because of accessibility issues.

SUZANNE  – We hear a lot about the amazing healthcare system in Canada. And I’m holding my hands up and quoting, free – free healthcare in Canada – and I’ll get onto that topic in a second. But there’s months and months of wait times. And so actually, if you do an Internet search of Canadians seeking care in the US, it’s usually wealthier Canadians or high profile politicians that will come to the US to get procedures done that they cannot get done in a timely fashion in their home country. So that could be considered medical tourism as well. And the United States takes in a lot of people.  There’s actually visas that they grant for medical purposes, for people to come into the United States. And many institutions have benefited quite greatly off of that. So medical tourism goes both ways and all ways actually.

SUZANNE  – And if I can, I’m going to circle back to the Canadian comment about free healthcare. And I think we’ll see a lot of this especially in the upcoming election year.

JANA  – Well, sure. I was going to ask about that.  Well, yeah, I mean, as long as you’re going down that road, we might as well have you weigh in, because you’ve, you know, you’ve been exposed to so many different healthcare systems, on what the candidates especially on the left are saying and what they’re offering.

SUZANNE  – Well, let’s talk about the word free in the first place, you know, we-

JANA  -well, there’s no such thing.

SUZANNE  – We touched on, like, quality and best in healthcare. Let’s touch on free.  Let me first say, because again, I teach university students who are all about free stuff. And I can’t say I blame them, because they, you know, they don’t make a lot of money, they can’t afford a lot of stuff. They want free stuff. And I’m sure they’ll lament – and I’m quoting again, with my fingers – free university, or free college, because they’ll have graduated by that time. Let me just say this. Nothing is free. I don’t know of any single doctor, any single hospital administrator that’s working for free. Somebody is paying for this. And what that means is that you and I and everybody else listening to this, if you’re a taxpaying citizen, you’re paying for this.  So nothing is free. Let’s get that very, very clear.  And I just like to make that point because I think a lot of people just get enamored with, Oh, it’s free.  It’s not free. Somebody is paying for it, and it’s you and me and everybody listening. So somebody is paying for that.

SUZANNE  – And so when we look at different healthcare systems, whether it is in Canada, or it’s in Europe, and these are obviously the ones that are the most lauded, we can see tax rate structures upwards of 75%. So think about that from an individual perspective.  Do you want to be paying 75% of whatever it is you make, whether you make $40,000 a year or you make $400,000 a year, countries like Luxembourg or France or Switzerland-

JANA  -Denmark…

SUZANNE  -again, it’s upwards of, and it’s based upon obviously the amount of money that you earn.  But their tax structures are much higher, because there are many more services that the government is accounting for. So yeah, that’s my soapbox on cost-free. There’s really nothing that’s free, and it really is up to each individual person to determine how much of a risk that is for them.  If, you know, somebody wants to take 75% away from my $40,000 a year – heck, if they want to take 50% away from my $40,000 a year – it may not fully equal out to what, say, the US system is currently charging. And again, depending upon your healthcare plan, you could be paying from an individual perspective, anywhere from $600 a month as a low, to upwards of say, $5,000 a month as a high.  And I know families that are paying upwards of like 23, $25,000 in healthcare coverage for their family.

JANA  – Right – for the entire year.

[MID-SHOW BREAK]

JANA – Suzanne, this is a 26-minute film, but you traveled to so many more countries portrayed in the film. I’m wondering what you left out. It must have been kind of hard to eliminate footage.

SUZANNE  – It was.  It really was.  We really focused on the interviews that had the most impact. And obviously when there’s emotion, it makes great film.  So anybody who was angry, or anyone who was really passionate about something, made the film. So we actually didn’t hear from any of the medical journal editors or publishers. And they were very, very interesting. We actually interviewed some electronic medical record CEOs, that had fascinating feedback as well.  We went to – and I’m trying to think of some of the other countries because in the film, we really only show Singapore, I believe we show Hong Kong, we show India, France, UK.

SUZANNE  – And we went to a number of countries in Latin America and the Caribbean. And what we learned there, both of how they care for the local people. We went to Mexico, Belize, Honduras, Costa Rica, we went to a number of different places in the Caribbean. And it was pretty fascinating, too, to see, especially in the Caribbean, how the local healthcare runs alongside the healthcare for tourists. And we actually got to see a number of locations that have emergency medicine combined with air evacuations. So in certain countries, they may specialize or have very limited access to, say, heart centers.  Or maybe they’ll do a couple of heart procedures, but not other ones.

SUZANNE  – And what I thought was really interesting, especially in some of the Caribbean countries, where one side of the island might have alliance to France, another one might have alliance to the Netherlands. One might do evacuations to Colombia. Another one might do evacuations to Miami. So it was really kind of interesting just to see how healthcare is conducted on really a global scale in such a small country, that caters to a highly touristic population.

JANA  – Did anyone question your credentials? Did you get any pushback?

SUZANNE  – Sometimes, but not always.  You know, in some of the hospitals that we went to, some were expecting us and so we had proper formal interviews with them.  Bumrungrad was one of them.  A couple of them in France, for instance, a couple in London.  Aruba, we did.  And oh, there was a couple other Caribbean countries where we had proper interviews. Mexico, we had a couple of proper interviews – you know, where everything was set up beforehand. In some cases, we did not.  And-

JANA  -you went undercover.

SUZANNE  -my hair was very long.  I went undercover. My hair was very long at the time, and I would basically put my iPhone in a front chest pocket, cover the phone with my hair and walk into the hospital. And there were a number of times when no one questioned me. And I walked into a pediatric ward in – actually a couple of places in the Caribbean, as well as in Latin America, as well as in some parts of Asia. I had walked into a surgical center, actually two surgical centers, one was in Asia, and somebody did stop me and I had a business card on me.  I gave the business card, they looked at it, nodded and let me be. I don’t know if it was that they couldn’t read what I had on my business card. I don’t know if I looked very authoritative, and very confident. And this is actually how – I’ve heard – that con men actually get away with things is because they’re so confident they get away with stuff. And I guess I must have looked very confident. Again. I didn’t look like I was carrying a camera. The camera was in my pocket. Of course, once I got past security, I would push my hair away and just start filming

JANA  – That’s incredible, to me.

SUZANNE  -Well, there was one story, and actually I was friends with the hospital CEO at the time, and it is a top hospital in London. I won’t say the name of it, but they do a lot of medical tourism. And I would say actually upwards of 50% or more of their patients come from other countries. So they’re highly attuned to an international clientele. And I had stopped in there on a weekend day – it might have been a Sunday, actually – and walked past the security guard, started walking to the elevator, and the security guard came after me. And he said, Excuse me, Miss, it is after hours. Because it was on the weekend. And he said, I need to know, you know, are you planning to visit a patient? And I said, Yes, because I didn’t know what else to say. And he asked me for the name. And of course I knew what mostly the patient population was. So I gave a name that would be indicative of that patient population, just praying to God that there would be nobody there by that name. And thankfully that person had checked out a week prior.  Oh my gosh.

JANA  – Was that a name that you made up?

SUZANNE  – And I was like, Oh, I didn’t know, thank you very much. It was a name I made up. Yeah.  I knew it would be a popular name, of a potential patient.  But then I don’t know what I would have done if he had said, Well, here, let me escort you to the room.  I guess I would have just gotten additional footage.

JANA  [laughs] – Exactly.

SUZANNE  – Yeah, that was my only like, “Oh, dear” moment, of, Oh, dear. What am I going to do?  Yeah.

JANA  – Right.  It’s pretty amazing that you were able to be an observer in operating rooms.

SUZANNE  – Amazing or foolish, as my parents would say. [both laugh]

JANA  – This was in France, right? Where you sort of mentioned that you saw healthcare, politics and profitability can go hand-in-hand. Yeah, I was struck by that observation that among the many people you spoke with in the hospitals in France, the individual was always, as you said, At the heart of sound management and decision-making, which is really different than it is in the US, right?

SUZANNE  – Yeah. What I was amazed by, honestly, in France was that we met with politicians, we met with medical device CEOs and other CEOs in the medical ecosystem and microcosm, basically, as well as with hospital CEOs. And what I found really interesting, they all knew each other. They all had regular meetings with each other. They all talked about what was needed. They were extremely transparent with their pricing and their costs. So it wasn’t just the pricing, it was the cost. And of course, France has a completely different structure than the US.  They do have a universal healthcare system. It is government mandated.  Again, they’re one of the countries that has a very high tax base. But every citizen is given a – it’s called a Carte Vitale, and it’s basically a card that allows you to visit any doctor or hospital and have a number of different procedures performed that are covered under the French Health Authority.

SUZANNE  – Another fascinating feature that I thought, with the Carte Vitale, was that if I went to Dr. A on Monday, and then had a different visit with D. B on Thursday, and then maybe had a second opinion with Dr. C the following week, I would just scan my Carte Vitale once I entered into the facility, and then poof, all of my medical records appear. So I don’t have to keep going from facility to facility to get the copies, or even, you know, having to pay for the copies in some cases, or have to run down there myself and then realize that because they’re running some different kind of electronic platform that they can’t be read by the other facility, as is very common here in the United States.

SUZANNE  – And part of it is, you know, we do have a very free market economy, for which I am grateful, and I obviously depend upon, but there are some limitations to that as well, especially when there is not really competitive collaboration here in this country. There’s a lot of competition, but that competition doesn’t always lend itself to the best interest of the patient, or who you’re actually trying to solve an issue for.  And I saw that very vividly in France, even when we were invited into an operating theatre to actually film a surgery.

SUZANNE  – Now, I’ll actually give you a special little story. We didn’t know it was a live surgery.  We thought that they were basically doing a mock surgery for purposes of the film. It wasn’t until, like, some blood spurted and I looked at my producer, and he looked at me and we both mouthed some words that I shan’t repeat here, but we just looked at each other with huge wide eyes like, Oh my goodness. And after we had finished filming the scene, and I think you see in the film, the surgeon is basically raising his hands above his head because he’d finished this very complicated procedure. And our cameraman Luigi, who’s Italian, said, Wow, that was like the most realistic surgery I’ve ever seen.  I’m like, yeah, that’s because it was.

JANA  – I wonder if the patient was told?

SUZANNE  – I don’t know.  I don’t know that, either.

JANA  – That of course would be a huge privacy violation here in the United States.

SUZANNE  – Totally.  Totally. Exactly. So that was kind of like, Oh, wow, um, this is kind of the real deal. But what I found really amazing, we had a great conversation afterward with the surgeon, with also the hospital CEO. And we’d had a conversation with a politician for that area. And they’re just so completely candid about, what is best for the patient?  And also, you know, what is going to meet the needs of the hospital, in terms of the types of procedures that are coming up that they’re seeing, what are some of the new innovations that are coming up, that can be utilized by the various positions.

SUZANNE  – It was just such a nice conversation.  And it wasn’t just one conversation. We were there for a week in various parts of France, and had these types of conversations every single day. And it seemed, just based upon the relationships that I witnessed between the various players, that this was an ongoing situation. And I contrast that to here in the United States, where I think really the only people involved in the conversations are insurance companies, healthcare providers and politicians. And it completely leaves out either the innovators or the patients who are really at the heart of why we’re doing all of this.  Where are the patients?

JANA  – Right.  It’s pretty much the only business where the consumer is completely left out of the process, in terms of-

SUZANNE  -I would agree with you

JANA  -knowing what things cost, and-

SUZANNE -yeah, it’s just amazing, to me.

JANA  -and… yeah, it’s really something.

SUZANNE  – Well, what I also find is interesting, you know, we’re currently in an open-enrollment period. So going back to your opening of like, you know, nothing scares you more –  hey, this is scary.  Why do we have an open enrollment period? Could you imagine somebody coming up to you and saying, you know, I need you to forecast all of the broccoli you’re going to eat next year. We need to buy it now.  Or if I went to an organization said, Hey, forecast, your annual travel, and you can only buy the travel now and, you know, if you need to buy travel next year?  Too bad. You’ll have to wait till October when it’s open-enrollment on travel. There is no other industry that does this. Why do we settle for this?

JANA  – Good question.

SUZANNE  – Seriously.  Why do we settle for this? And I think it’s because, again, we don’t know any better. And I think because healthcare can be so complex, and the culture within the United States is that you must have a medical degree and have to have gone through many years of schooling in order to be educated enough to have an opinion about healthcare, even though this is your body, that we just accept what has been handed to us. And again, that comes back down to patients having the courage – because I think it does come down to courage – as well as some of the knowledge to ask, Well, how much does this cost? And to ask if you could have a second medical opinion.  You’re within you’re right for that.

SUZANNE  – But I know so many people, and especially seniors, that won’t ask because they’re afraid to offend the doctor. And if you offend the doctor, the doctor won’t treat you, or he won’t be nice to you, or she won’t refer you on.  We don’t settle for this in almost any other commodity that we buy. And maybe again, it’s because we don’t see healthcare as a consumer product, even though it is marketed to us as consumers, even though employers right now are paying for it. I’m obviously advocating for change in that model.  But every patient in America, which means every person in America, has that right to ask the questions that needs to be asked.

JANA  – I’m going to take it even one step further and argue that our fear of death prevents us from acknowledging that we have health problems, and we put things off as long as possible, because we’re so afraid of our own demise. And I think that’s maybe a little existential, but I think that we’re used to being taken care of – many of us – through our employer-based health care plans. And as you pointed out, with the growth of the gig economy, the model of healthcare is outdated, our economic system is outdated. So you’ve got those things. things going against, you know, the health care system. And then, like I said, I think people are really afraid to talk about decline. And that might maybe have something to do with it. I don’t know, I could be wrong.

SUZANNE  – I think along those lines.  I think, since having cancer at the age of 33, and certainly one of the higher morbidity of cancers, of ovarian cancer-

JANA  -yeah.  How frightening.

SUZANNE  -there is not a day that I don’t think about death. And I know that sounds really morbid. But I would also say it probably lends me to have an amazing life, because I don’t know how much time I have. And it’s the reason why I get up every day with a smile on my face, that I am alive and like I’ve got this gusto to accomplish something for today. So I would agree with you. And I think that other people that I know that have had near-death experiences, also have that finite look into their lives, and having that proactive look to extend our health, because it really is incumbent upon each of us.  But how do you instill that sense of personal responsibility into somebody who doesn’t see the urgency in it? I don’t know.

JANA  – Yeah, I agree with you.  Well, you’re not going to name countries and you’re not going to name hospitals. So what you are going to do is talk about this wonderful company that you founded, that will help people, because I wanted to give listeners some information that maybe they can use. And you’ve got Gauze the company, which you founded.  And tell us what that’s all about, because I know that’s going to be useful for folks to hear about.

SUZANNE  – Oh, thanks. So the film took us about a year and a half to actually film, and visit all those different places. And then it took us probably another year and a half or so to edit. And when you’ve got almost 100 hours of film, and you’re trying to cut it down into something that can be utilized on television, and obviously this was shown on PBS, you know, it took a long time. And then in the meantime, it really got us focused on, well, how many people actually do get sick outside of their home countries?  Because I travel a lot. Like I said, I’ve been in more hospitals in different countries than most people have traveled to.

SUZANNE  – But I started doing some research, and I found that the United Nations, as of last year, said that there was 1.4 billion people that traveled internationally. And of those, and I think it’s a CNN report, stated that about 47% of people got sick while traveling. And actually there is a survey by Teladoc that said that 45% of people got sick, requiring hospitalization, while traveling.  So then I started looking into, well, what do those people do?  Because I know what I did.  I came home, and I was misdiagnosed at home. So I couldn’t trust there. I couldn’t trust here. And then I realized that there’s really four things that people do when they do get sick abroad.

SUZANNE  – And again, we’re looking at 1.4 billion people traveling, of which let’s just say half – so 700 million people are getting sick crossing a border. And for most Americans, they’ll do nothing. They will come home and wait and get care back at home, for a couple of different reasons. They don’t speak the language. They’re unsure of the quality. They’re unsure of, actually, the healthcare system.  How do they pay?  Because in some countries, you actually might be turned away because there is no way for you to pay. But in some countries, you actually would get care, even though you wouldn’t have to pay a thing. So there’s a lot of confusion about healthcare internationally.

SUZANNE  – And I wanted to see, again, what do people do? So sometimes they do nothing.  The majority of the time, they do nothing. Other times they could Google someplace. And actually, my husband and I, we do this in almost every place we travel to, just to see where Google will point us to. So we were in Dublin, actually. And my husband thought, Hey, well, you know, language isn’t a barrier for me, I can at least go ahead and Google someplace and see where it brings me to. And it brought him to – and I will name this hospital – it brought him to Mater Misericordiae [University] Hospital, something like that.  And it was basically a maternity hospital, which as a dude is not going to help him. So Google was a bust. So Google’s not really going to, you know, show you where’s a great quality place that speaks your language and will take you, [or] if it’s, you know, a female or a children’s hospital.

SUZANNE  – Another option is, you could ask a local person. You could ask the concierge at your hotel, but they’re likely going to give you where they would go as a local. And again, if it’s a country that has a government-sponsored plan, where there’s no way for you to either be accepted into the system, it’s not going to serve you well. And we know a number of people actually that have had that experience where, like in Venezuela, for instance, obviously government-run system, the guy waited in line for about three hours and finally went up to the front and said, Look, I’m not feeling well, I think I’m deteriorating here. I can pay you.  And they said, We don’t care.  Get back in line. And so for him, obviously talking to a concierge or a local person wasn’t helpful.

SUZANNE  – And then finally, somebody could get an insurance, whether it’s medical assistance or travel insurance.  But they also have very limited networks. And so they might have one hospital per city or per country, which if you’re in a secondary or tertiary city, that might not help you either.

SUZANNE  – So we wanted to come up with a system that would effectively join or unite people with appropriate healthcare facilities outside of their home countries for when they do get sick abroad. And it would be on a platform that was confidential.  Your boss wouldn’t need to know that you got sick, or your study abroad program wouldn’t need to know. It would be immediate. It would be on an app, or on a web app or API basis.  You could find the place immediately, you wouldn’t have to call up someplace, you wouldn’t have to Google and hope that Google vetted it appropriately, and it would be accurate.  And what that means is it would be vetted facilities. And so we created Gauze as a healthcare technology company that really is a database of hospitals outside – well, mostly outside the United States.

SUZANNE  – And so we have about 30,000 hospitals outside the United States, and we just connect people with these facilities.  And we look for things that are important to an international traveler.  And we’re not looking necessarily at medical tourists.  Medical tourists, I think, have a very different mindset than an accidental patient.  So like I said, there may be 700,000 to 7 million medical tourists. But, you know, as I just explained, there might be 700 million accidental patients, ranging from somebody who’s got an upset tummy, or maybe had a skiing accident, or has a vomiting child – the likelihood of being an accidental patient are much greater than being a medical tourist.

SUZANNE  – So the things that we do look for, language is number one.  And we don’t look for hospitals that just speak English. We look at hospitals that if you’re Greek and you’re traveling to Peru, are there any hospitals that speak Greek?  Or do they have access to an interpreter? You might be surprised to know that the number of hospitals in Brazil that speak Japanese is the second highest in the world.

JANA  – Wow. I am surprised.

SUZANNE  – Yeah, right?  So it’s pretty interesting. The work that we do, we look at, again, languages, we look at hospitals that are open 24 hours.  You might also be surprised to know that about 20% of hospitals outside of London, close for the evening. So you really can’t get in, if you’re one of the shires out in the countryside. So you might actually have to go to a place that’s farther away. So we look at accessibility.

SUZANNE  – We also download published price lists.  France is amazing for having published price lists, as is – many countries in Latin America, as well as Southeast Asia. And then we also look at the doctors themselves.  How many doctors are on staff?  Hospitals are famous for letting you know how many beds they have.  On almost every hospital website or advertisement they might say, We’re a 420-bedded facility.  Well, what does it mean to you as a patient? Nothing.

JANA  – Uh-huh.  Nothing.

SUZANNE  – It means nothing. It’s basically a financial conversation of, like, Okay, we have 420 beds, and if we have like an 80% occupancy rate, and we charge, say, $1,200 a day, it really comes down to a financial conversation on the number of beds.  We want to know, how many doctors per beds are there? How many doctors per patient? What is that doctor to patient ratio? That’s important for us.  It’s important for our patients.  And then, furthermore, how many of those doctors have been trained abroad?  Because having a doctor that has been trained outside of their home country, whether it’s an Indian doctor that’s been trained in the UK, or an American doctor that’s been trained in the Dominican Republic, it gives that doctor actually an understanding of the culture.  Whether it is your actual culture or not, it just gives them an empathy toward internationalists.  So we’re interested in finding out that information as well as the number of doctors that have a board certification, which is not always the case, anywhere, not even here in the United States. So we ask about 40 or 50 different questions. And we’re not there yet, but we are working on creating an algorithm that will effectively rank hospitals on actual scientific objective data as opposed to peer review, which is done by US News and World Report here in the United States.

JANA  – Uh huh. And so have you launched the website? Is there an app that people can go to?

SUZANNE  – So we are not yet ready for individual consumers. We are accepting and we’ve started accepting customers in the corporate realm. And we do look to open it up to consumers in mid-2020.  So stay tuned on that.  Keep checking our website.

JANA  – Okay, great. Well, why don’t you provide us with that website? Where can folks learn more about this film and the work?

SUZANNE  – Awesome. It’s www dot gauze – and that’s G-A-U-Z-E – dot net.  And actually, I don’t know how much time we have left, but I do have like one other piece of information I would like to share with your audience regarding healthcare as a business.  We often laud nonprofits, and talk about healthcare in nonprofit terms. And yet, when we look at the financial structures of healthcare facilities, we see that there’s really three or four different structures. It could be nonprofit, it could be for-profit, it could be government, and it could also be military. And obviously each of those has their own different parameters.

SUZANNE  – One caveat, I’ll say, actually on the military side is that many countries, particularly in Latin America, as well as Southeast Asia, we found that the military hospitals had the most advanced innovations, and the most adept physicians.  And the military were the best attended-to patients in that entire country.  That is not the case here in the United States, unfortunately.

SUZANNE  – But I also go back to the financial implications of how an organization is structured. And what I find interesting, there was a recent case here in Philadelphia, where I live, where a for-profit hospital just declared bankruptcy back in September.  And they were about $3.7 billion in patient revenues. And they had been running a deficit for years and years and years, to the point where finally the company said, Look no more. There was this huge outcry in the city because this hospital predominantly took a Medicaid approach, where they were one of the few hospitals that really catered to the needs of a poorer demographic. And because of them accepting this demographic, and obviously, leading to reduced reimbursements by the government, from a managerial standpoint, caused them to go bankrupt.

SUZANNE  – And yet, I contrast that with their nonprofit – and again, I’m putting my hands up in quotes – nonprofit peers, who are running at $6.8 billion in patient revenues, or $4 billion dollars in patient revenues. And whereas this one hospital that I had mentioned that had gone bankrupt, had a very sizable percentage of either charity or goodwill extensions for the work that they were doing in their community, these other, again, nonprofit hospitals, ranged between two-tenths of a percent and 4% on the charity scheme. So who’s really nonprofit here?

SUZANNE  – And that, too, is something that I think needs to be looked at in terms of, if we are going to go to a single payer system – and again, if people are clamoring for Medicare or Medicaid for all, we’ve seen what Medicaid for all can do: it causes certain hospitals to go bankrupt. So what is that fine balance? And that’s what I think we need to look at, and not just broad brush it and broad stroke and say, Oh, Medicaid for all.  Because there are certain financial implications to that as well.

JANA  – Sure. Is there any way for folks to actually see this film?

SUZANNE  – Yeah, so we had to wait actually, until all of the film festival screenings were done. We are now complete. We will actually be posting a link on our website. We are actually working with a couple of online streaming companies to get it streamed. So again, please check out www.gauze.net. It should be up, I want to say at least by the end of 2019.  At the very latest by the beginning of 2020.

JANA  – Okay, great. How is your health?

SUZANNE  – Oh, my health is – my health is fantastic. Thank you for asking.

JANA  – Good.  Good.

SUZANNE  – Yeah, I appreciate that. I’ve been cancer-free for 18 years. And yeah, by the grace of God, I’m still doing really well. And I had the heart surgery, I fixed all that.  That should have been done 40-something years ago, as well. But, you know, I take the necessary precautions. I know that I, ultimately, am the only person responsible for my health. Not my husband, not my family, not the government. It’s me. And I think when more people start to realize that they are not only responsible for their health, but they have the privilege to take care of themselves in a proactive manner, I think it makes all of us more healthy.

JANA  – That sounds like a great place to end. We’ve been speaking with author and filmmaker Suzanne Garber about her documentary film, “Gauze: Unraveling Global Healthcare.”  Suzanne mentioned her website in the show, but we will also link in the show notes to both the film’s website and Suzanne’s website Gauze.net. But if you want to dive in right now and just explore the film, I encourage you to do that. It offers a really helpful perspective to us Americans who tend to be somewhat navel-gazing and thinking, Oh, this is the only way.  Well, it’s not the only way and Suzanne’s film does a really good job of putting this in perspective. So if you want to dive in right now go to Gauzethefilm.com – all one word – Gauzethefilm.com, and check it out.  Suzanne, thank you so much for making this fascinating film and of course, for being on The Agewyz Podcast.

SUZANNE  – Well, thank you so much for having me on the show.