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Health care experiences of U.S. Retirees living in Mexico and Panama: a qualitative study

Health care experiences of U.S. Retirees living in Mexico and Panama: a qualitative study Background: Retirement migration from northern countries to southern countries is increasing in both Europe and North America, and retiree experiences will impact future migration and health services utilization. We therefore sought to describe the healthcare experiences and perceptions of retired U.S. citizens currently living in Mexico and Panama. Methods: 46 retired U.S. citizens (23 per country) who had been hospitalized (61%) or had a chronic health condition (78%) in two regions per country with large communities of retired U.S. citizens were identified. Detailed semi-structured interviews were conducted to explore experiences with, attitudes toward, and costs of healthcare. Interviews were analyzed using quantitative and qualitative methods. Results: Respondents averaged 68–70 years old, were well educated, had few physical dependencies, and had moderate incomes. They praised physician services as more personalized than in the U.S. and home care as inexpensive and widely available, expressed favorable opinions regarding outpatient and dental care, gave mixed ratings on hospital services, and expressed concerns about emergency services. Numerous concerns about health insurance were expressed, including the unavailability of Medicare and reductions in Tricare. Payment concerns and lack of data on local health providers made deciding where to obtain services challenging. Conclusions: Retirees living abroad report dilemmas regarding healthcare choices, insurance availability, and quality of care. As this population segment grows, pressure will increase for policy and business solutions to existing medical care challenges. Keywords: Retirement, Migration, Medical care, Mexico, Panama Background warmer climate, lower living costs, and a desire to Trans-national migration of retirees is an increasingly experience another culture [1,2,4,5]. common phenomenon in Europe and the United States. As of 2011, an estimated 6.32 million non-military The common European pattern involves retirees from American citizens lived overseas, about half of whom northern countries such as Germany, the Netherlands, live in the Western Hemisphere [6]. Of these, a significant Great Britain, Norway, and Sweden relocating to southern and increasing proportion are retirees living in Latin countries such as France, Italy, Spain, and the Canary America, with Mexico and Panama currently being the Islands [1]. In the Western hemisphere, a similar pattern most popular destinations [2,3]. In 2012, the U.S. Social has evolved, with Canadian and U.S. citizens increasingly Security Administration reported that nearly 360,000 selecting retirement destinations in Latin America [2,3]. retired workers were receiving benefits abroad, a 20 Reasons most commonly offered for migration include percent increase since 2007 [7]. With the upcoming retirement of over 100 million U.S. “baby boomers” in the next 30 years, many of whom have limited retirement * Correspondence: philip_sloane@med.unc.edu savings and an increasing number of whom are consider- Program on Aging, Disability, and Long-Term Care, Cecil G. Sheps Center for Health Services Research, University of North Carolina, Chapel Hill, ing non-traditional retirement alternatives, the number of NC 27514, USA U.S. citizens retiring in Latin America has been projected Department of Family Medicine, University of North Carolina, Chapel Hill, to mushroom [5,8]. NC 27514, USA Full list of author information is available at the end of the article © 2013 Sloane et al.; licensee BioMed Central Ltd. This is an open access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Sloane et al. BMC Health Services Research 2013, 13:411 Page 2 of 8 http://www.biomedcentral.com/1472-6963/13/411 Health care is an important issue for older persons; participants, and study procedures were approved by however health care issues among retirees who migrate the Institutional Review Board of the University of North abroad have received relatively little attention in the Carolina. Ethical approval was not obtained from Mexican retirement migration literature [1]. For European migrants, and Panamanian authorities since only U.S. Citizens medical care is usually reimbursed by national health participated in this research. No Mexican or Panamanian insurance plans that pay for emergency and planned nationals were involved in any way in the subject accrual treatment anywhere in the European Union [9]; however or data collection. satisfaction with services has been reported to be mixed [10], and major health events can be unusually disruptive Data collection [11]. For U.S. migrants, the issue of healthcare abroad Interviews in Mexico were conducted in March 2007 and is even more challenging, as neither Medicare (the in Panama in June and July of 2008; all except for one were government health insurance for senior citizens) nor conducted in person, and all were audiotaped and tran- most private health insurance plans cover expenses scribed for analysis. Each interview lasted approximately incurred in other countries [12-14]. Therefore, how 45 minutes and followed a semi-structured format. Topics retired U.S. citizens living abroad manage their healthcare addressed included: is a particularly important issue [2,8,15,16]. Given the anticipated growth in retirement migration  personal health and resources (e.g., functional status; to Mexico and Central America, information about the activities of daily living; health status; health actual experiences of retirees who have required healthcare insurance); while living abroad would help inform personal, corporate,  healthcare experiences while living abroad and policy decisions regarding international retirement. (e.g., chronic illness care, serious acute problems, Therefore, to learn more about the healthcare experiences hospitalizations); and needs of U.S. retirees living abroad, we conducted and  payment for medical care (e.g., out-of-pocket expenses; analyzed semi-structured interviews of retirees in Mexico cost of specific incidents such as hospitalizations or and Panama who had used local healthcare resources for trips back to the U.S. for health care); acute hospital care, chronic illness management, or both.  opinions about the quality, availability, and cost of healthcare in the host country (e.g., desires in a Methods health care provider; experiences with providers in Participants and recruitment the U.S. and Latin America; whether or not they In each country, two regions with large numbers of had ever postponed care and if so why); expatriate American retirees were targeted for recruitment,  future health care plans (e.g., what they would do using a purposive sampling approach. In Mexico, re- if they had a serious illness or needed long-term cruitment was carried out in San Miguel de Allende and care services); and Chapala, both of which are medium-size communities  comparison and contrast with the United States within an hour and a half of large cities. In Panama, (e.g., experiences with health professionals; cost). recruitment focused on Panama City, the capital, and Boquete, a rural region in the north. Participants were Interviews were conducted by trained research assis- recruited using notices in English and bilingual newspa- tants with experience in qualitative data collection and pers, postings to local expatriate blogs and list serves, health services research, who were encouraged to pursue networking with expatriate societies, and acquaintances themes that arose and seek clarification as required. of respondents. Our goal was to interview retirees who required sig- Data analysis nificant use of the local healthcare system. Therefore, Data analysis was conducted using a grounded theory participants had to be: native born U.S. citizens who were approach [17]. The first step involved developing codes retired, aged 55 or older, had lived full-time in Mexico or based on the content of each phrase, sentence or para- Panama for at least a year, and either have a history of graph. This was done by four coders from different hospitalization in Mexico or Panama during the previous disciplines (medicine, social work, and psychology) who two years or have a chronic illness requiring ongoing compared and agreed on a final list of codes. Next, the medical management and monitoring. team members independently coded the transcribed Of 49 eligible volunteers, three were not interviewed, interviews for manifest and latent themes, as outlined by two because the interviewee did not keep the appointment Padgett [18]. and one who withdrew due to hearing difficulty. The final Quantitative data were imported into SAS 9.1® and sample included 23 respondents from Mexico and 23 from checked for accuracy and logical errors, with discrepan- Panama. Written informed consent was obtained from all cies resolved by reference to the transcribed interview. Sloane et al. BMC Health Services Research 2013, 13:411 Page 3 of 8 http://www.biomedcentral.com/1472-6963/13/411 Frequencies and averages were computed, and analyses the facilities adequate. Hospital physicians largely spoke compared frequencies and distributions of responses by English, and many (especially in Panama) had some U.S. country. Continuous data were analyzed for significance training. Many respondents remarked that the hospital using the t-test option in SAS 9.1®; categorical data were staff provided more time and personalized attention than analyzed using the Chi-Square test or, as appropriate, they had experienced in the U.S. One reported that the Fisher’s Exact option. “doctors are not frantically busy like they are in the United States,” and several commented about nursing Results care being more attentive. A few respondents in Mexico Study respondent characteristics are displayed in Table 1. reported choosing to use the public hospital system (the The mean age was 69.9 for the Mexican respondents Instituto Mexicano del Seguro Social [IMSS]), which can and 68.1 for the Panamanian respondents, with the range be purchased by immigrants after a waiting period. IMSS from 59 to 87. The majority were married, had a college hospitals were reported to have less access to technology degree, had few dependencies in daily activities, and had than U.S. hospitals, however, and patients were expected some Spanish proficiency. Reported income levels were to be accompanied by someone who would attend to moderate, with approximately half reporting monthly personal care needs. incomes below $3,000. Twenty-eight respondents (61%) For specialized procedures, residents in smaller commu- had been hospitalized in Mexico or Panama, and 36 (78%) nities reported having to travel to larger centers, occasion- reported a chronic illness that required ongoing care and ally at considerable cost or hardship. One respondent, for monitoring. In general, the two samples did not differ sig- example, had to move from Boquete to Panama City for nificantly in demographic or health status characteristics, two months to receive daily radiation treatments. except for greater reported income and fewer white Persons with Medicare often expressed a desire to go respondents in the Panamanian sample. back to the U.S. for hospital care, some citing quality In qualitative analyses 38 open codes were developed, and all citing cost. The risk of delaying care and the reflecting four overarching themes: availability, quality cost of travel were cited as significant drawbacks to and cost of care; relationships with providers; paying for this strategy, however; one reported spending $13,000 healthcare; and making healthcare choices. to return to the U.S. by private Lear jet during a health emergency. Availability, quality and cost of care A unique aspect of Panamanian healthcare is the avail- Both Mexico and Panama have parallel public and private ability of a military hospital in Panama City. Unfortunately, healthcare systems, with the overwhelming majority of veterans in our sample reported problems communicating interviewees using the private system exclusively or most of up the chain of command, because they often had to the time. Opinions about quality were mixed but generally contact the U.S. to determine whether a given service favorable regarding access, visit length, price, and commu- was covered by their benefits. As one military retiree nication. Negative reports focused on uneven expertise, noted, “There’s no local direct contact with the VA or language difficulties, acute care costs, and less available Department of Defense or anybody who can give us technology. information….They give us a phone number we can call… (and) there is a whole lot of time involved in trying to com- Outpatient care municate by telephone. We get a lot of menus. Sometimes Most respondents used the private system for outpatient we don’t get an answer at all.” care, reporting easy access to physicians and generally praised the services received. A pervasive theme involved doctors providing longer Emergency services appointments and more personal service than their U.S. Respondents in both Mexico and Panama described counterparts. As one respondent commented: “You can emergency services as needing improvement, particularly get an appointment with a specialist, and for 500 pesos in regard to transport and paramedic care. As one re- they will give you an hour or more of their time, give you spondent noted, “what they call paramedics down here are their cell phone number, and return your emails.” Mental not paramedics; they strictly transport you to the hospital. healthcare was reported to be less developed than in the They cannot administer drugs….Their first aid training is U.S., however, and record-keeping was viewed as uneven very basic, and they have no requirement to get annual and often inferior. updates.” The availability of blood supplies in the event of an emergency was also cited as a cause for concern. Hospital services However, efforts were reportedly being made to improve Nearly all respondents reporting hospitalization had used emergency services in both countries, often with assistance private hospitals and reported the quality to be good and from retirees or U.S. based physicians. Sloane et al. BMC Health Services Research 2013, 13:411 Page 4 of 8 http://www.biomedcentral.com/1472-6963/13/411 Table 1 Characteristics of study participants Demographic characteristics Mexico (n = 23) Panama (n = 23) P-value for difference Mean (SD) Range Mean (SD) Range Age 69.9 (6.8) 59.0 – 87.4 68.1 (4.5) 60.8 – 80.6 0.40 Years living in Mexico or Panama 7.2 (5.6) 1.0 – 20.0 6.4 (12.2) 0.6 – 60.6 0.78 Spanish proficiency (0 = none to 10 = native) 4.7 (2.3) 0.0 – 9.0 4.2 (2.4) 0.5 – 8.0 0.51 N%N% Gender (female) 15 65.2 8 34.8 0.08 Race (White/Caucasian) 23 100 18 78.3 0.05 Marital status 0.29 Married 14 60.9 17 73.9 Widowed Separated/divorced 6 26.1 5 21.7 Never married 3 13.0 1 4.4 Education 0.13 High school or less 3 13.0 0 0.0 Some college 2 8.7 8 34.8 College degree 4 17.4 4 17.4 Post-graduate degree 14 60.9 11 47.8 Income (monthly) 0.04 $1,000-$1,999 6 26.1 2 8.7 $2,000-$2,999 8 34.8 8 34.8 ≥ $3,000 9 39.1 13 56.5 Medical and functional characteristics N % N % Hospitalized in Mexico or Panama during prior 2 years 11 55.0 17 73.9 0.22 Days hospitalized among participants hospitalized [Mean (SD), Range]* 4.9 (4.8) 1 – 17 3.3 (1.6) 1 – 6 0.36 Had a chronic illness requiring ongoing care 17 77.3 19 82.6 0.72 Requires supervision or assistance with: Feeding self 1 4.3 0 0.0 0.48 Walking a block 2 8.7 3 13.0 0.67 Dressing self 2 8.7 0 0.0 0.09 Bathing self 2 8.7 0 0.0 0.09 Using telephone 1 4.3 0 0.0 0.22 Shopping for groceries 2 8.7 0 0.0 0.14 Reliably taking medications 1 4.3 0 0.0 0.19 Handling finances 1 4.3 0 0.0 0.43 Depression 3 13.0 2 8.7 0.61 Incontinence 3 13.0 2 8.7 0.61 Number of medications [Mean (SD), Range] 4.9 (2.8) 2 – 12 4 (3.3) 0 – 10 0.39 *Outlier of 75 days removed from Mexican dataset; with outlier, mean (SD) = 11.9 (22.6), p < 0.01. Long-term care them as friends and knowing their entire family. As a In both countries home care was reported to be widely result, a common theme among many respondents was available, inexpensive, and of high quality. “Where I live, of planning to remain at home with services until they I can get a nurse to take care of me 24 hours a day for died. about $20 to $25 a day,” one respondent said. Several Few respondents knew about the availability of institu- employed full-time home care aides, often referring to tional long-term care. Some had not given it much thought. Sloane et al. BMC Health Services Research 2013, 13:411 Page 5 of 8 http://www.biomedcentral.com/1472-6963/13/411 Others, especially those with close ties to children in the communication with nurses and ancillary care providers, states, reported that they would return to the U.S. if they most of whom spoke only Spanish, was often perceived needed long-term care. as a challenge. “Language is a problem, particularly with the nurses or attendants or receptionists,” was a typical Dental care comment. Dental services in both countries were widely praised for high quality and low cost, except in rural Boquete where Paying for healthcare it was less available. Comments included “I know a lot of Healthcare costs were universally described as lower than people who come to Mexico regularly to get their dental in the U.S. However, virtually all interviewees expressed care,” and “you wouldn’t get a cleaning in the U.S. any- concern about lack of health insurance coverage in where near the quality of this.” general, and the unavailability of Medicare in particular. The reported median annual out-of-pocket expenditure Medication was $5,250 for the Mexican sample and $1,650 for the Respondents in both countries reported that most Panamanian sample. A few reported much higher out-of- medications other than narcotics were available with- pocket costs and several expressed concern about losing out prescription. They tended to appreciate the easy their savings from a high-cost illness or hospitalization. access, but some reported concern about potential use The experience of one interviewee illustrates this dilemma: of unnecessary or contraindicated medications. Costs “Last January I was involved in a car accident where I was varied and were reported to be increasing. As a result, hit by a bus. The police officer at the scene told the people interviewees with U.S. insurance often waited to refill there that if I could afford it, to send me to (a private medications during periodic visits to the States or bought hospital) because my chances of survival there are going medications online, processes that could complicate deliv- to be a lot better than my chances at the (public) hospital…I ery. As one reported: “We buy [medications] from Canada was in the hospital for two and a half months. The hospital on the internet because they are cheaper…Canada can’t stay cost $320,000 (U.S. dollars).” send them to Mexico, so we have to find someone in the U. Reliable, comprehensive, reasonably-priced local in- S. who is planning to come down…in four to six weeks, and surance plans appeared to be largely available. Most give them plenty of time to send it to the wrong place, not common were limited private plans from a local hospital to be delivered, or to be sent back for us to spend time on or medical group. One was described in this manner: “ I the internet and the telephone trying to find them, have don’t have a real health insurance policy … Ihave a very them sent back again, and have the person get them in limited HMO with a local group of doctors in [nearby city] time before they leave.” that is…very inexpensive … like maybe $200 a year… If we can find someone in that group, then we will get a discount.” Relationships with providers Retirees in Mexico can purchase IMSS insurance after Generous personal attention from healthcare providers a waiting period for approximately $300 U.S. dollars was a common theme of respondents in both countries. per year; however, the public system was described as One respondent said, “they spend a good half hour, confusing and many voiced concerns about quality. 45 minutes with you….It’s not like in the states where you Some respondents had state employee or corporate go to see your GP and if he spends 10 minutes with you, policies from the U.S. that extended benefits overseas; you’re fortunate.” Physicians were commonly reported to their reported reimbursement and satisfaction varied. One “go that extra mile” by giving out cell phone numbers stated, for example: “The insurance only paid about $175 and email addresses, making house calls, communicating of that $1,000 (hospital charge).” with other providers, negotiating payment arrangements, Military retirees universally complained about Tricare, even personally driving patients home or to the hospital. the U.S. military health insurance program. Until recently, One respondent characterized his care as “just the old, coverage for military retiree healthcare costs was available long-before-you-were-born style of medicine.” Respondents worldwide and considered excellent. However, recent also praised the dedication and quality of care received reductions in payment schedules and long delays in from home care providers. reimbursement have caused many healthcare providers In rare cases reports were less favorable. One inter- to no longer accept Tricare. One interviewee explained, viewee reported being “not totally thrilled with the way “Let’s say a doctor charges you $100 for a visit. He submits he [neurologist] acts towards us,” explaining that the his bill to Tricare. Tricare says, we’re only going to pay him physician was less respectful than her doctor in the U.S. $30, and of that $30, they are only going to pay 75%.” The This concern prompted her to consider returning to the U. result has been more expatriate retirees seeking care in S. for healthcare. In addition, though interviewees reported the U.S. or Puerto Rico, a process that is not always widespread availability of English-speaking physicians, practical and can lead to risky delays. One interviewee, Sloane et al. BMC Health Services Research 2013, 13:411 Page 6 of 8 http://www.biomedcentral.com/1472-6963/13/411 for example, had recently attended the funeral of a friend When asked about long-term care, the younger and whose Panamanian hospital stopped accepting Tricare healthier retirees often reported not giving it much thought. for his dialysis, and who subsequently died while awaiting Typical responses were “Ican’t really decide on that acceptance for care at a U.S. military hospital. because I don’t know what turn my health will take” Retirees who qualified for Medicare were universally and “I would just have to evaluate where we are at that upset about the lack of coverage. Many felt indignation point.” Those who had thought about the issue fell into at having to continue to pay a monthly fee for Part B two groups: those who would opt to be near family in coverage to avoid the risk of higher premiums if they the U.S., and those who would stay abroad and obtain later returned to the U.S.. Every interviewee wanted to in-home services. One respondent replied: “I’d stay right see Medicare benefits extended to retirees living abroad, where I am. I would find someone who would come in many of whom believed that the U.S. would gain financially every single day or overnight depending on what I need, from paying for less expensive services abroad. “It’s just and I would be able to afford it.” costing the U.S. government more and more to have us come back, especially for basic stuff,” one commented. Discussion The population of retired U.S. citizens living abroad is growing and is projected to mushroom in the coming Making healthcare choices years [2,3]. Because healthcare provision for retirees living No respondent in the Mexican sample spoke of having abroad is a common concern and has undergone little chosen to locate there for healthcare reasons. In contrast, systematic investigation, we interviewed retired U.S. citizens the availability, quality, and cost of healthcare were a in Mexico and Panama who had significant healthcare consideration for a number of interviewees in Panama, needs. Our interviews identified many strengths regarding which is booming as a medical tourism destination and health services in those countries, including lower costs, has several hospitals that offer insurance plans catering availability of high quality services, personalization of care, to U.S. retirees (including one in Panama City that is and in-home care. Many problems were also identified, in- affiliated with Johns Hopkins University). Moving abroad cluding concerns about consistent quality, reduced access for healthcare reasons was particularly true for retirees in to technology, decision-making challenges, inadequate their late 50s and early 60s who had not yet qualified for insurance coverage, and a desire to see Medicare extended Medicare, and for military veterans who were drawn by abroad. the existence of military healthcare in Panama. As is typical of Latin America, parallel public and private Regardless of the role of healthcare in decisions to retire healthcare systems exist in Mexico and Panama. The public abroad, virtually all interviewees described the task of systems tend to focus on the uninsured poor (though deciding where and how to obtain services as challenging. attempts to provide universal coverage are growing); Contributing to this problem were not only the insurance resources are limited; and service quality is highly variable issues described previously, but also the relative unavail- [19]. Persons with adequate resources, whether U.S. citizens ability of consumer information. One respondent spoke of or natives, tend to selectively utilize the private system having comparison shopped for the best hospital to have because of its reputation for higher quality, efficiency, prostate surgery in Dallas, using published statistics on and highly personalized care [20], as did the vast majority complication rates and patient satisfaction, and finding of our interviewees. Our respondents’ comments were no similar information available in Mexico. As a result, strikingly similar to those of Mexican immigrants to the most retirees depended largely on informal information U.S. who return to Mexico for health care in the private gathered by word-of-mouth, expatriate organizations, system – that doctors provide more personal care, providers they had already met, and internet list serves providers appear less motivated by money, and things can and blogs. get done faster [20]. Respondents who had Medicare reported weighing the Indeed, a particularly striking theme from our interviews costs of deductibles, co-pays, travel, and demands on was high satisfaction with physician providers, who were informal caregivers when determining where and how to often favorably compared with those in the U.S. Inter- access services. Some maintained a house or apartment in viewees frequently reported providers taking a personal the U.S. and returned regularly, in part to obtain medical interest in patients, routinely providing long appointments, services. Those who did not have a U.S. home base had and being readily available. Possible contributing factors higher travel costs. As one noted, “you have to pay for a could include true international differences in practice style place to stay, food, you’ve got to rent a car, airfare, and or differential treatment of U.S. retirees, perhaps in part then (hospitals) only keep you for a nano-minute…So the because they pay privately. Whatever the explanation, question is, do you go back or do you stay here and just this finding is in contrast to U.S. healthcare, which, in cross your fingers?” comparison of health systems in six developed countries, Sloane et al. BMC Health Services Research 2013, 13:411 Page 7 of 8 http://www.biomedcentral.com/1472-6963/13/411 was rated among the lowest in patient-centeredness, majority of which had been founded after 2004 [31]. In access, and efficiency [21]. Home care was another area of response to this trend, moves to provide better assurance high satisfaction, with many respondents extolling the of care quality are growing. For example, Joint Commission ready availability of high quality, affordable providers. International, an extension of the main U.S. healthcare Considering that the vast majority of U.S. seniors would accrediting agency, currently accredits seven hospitals and prefer home-based services to institutional long-term care, health systems in Mexico and two in Panama [32]. the existence of inexpensive quality home care could Major limitations of the study include the purposive constitute a significant attraction for retirement to Mexico nature of the sample and the respondents’ limited ability or Panama [22]. to judge issues related to quality of care received. Since Difficulty choosing where and from whom to obtain no census of retirees exists, the sampling method we care was widely reported, with retirees needing to network used is typical of that employed in interview studies of extensively to make choices. In particular, a lack of available migrant retirees [5,10]. Such a method limits drawing public data on provider credentials, quality, and outcomes generalizations from results, however, so our conclusions was noted. This situation is easily remedied; one solution should be considered hypothesis-generating rather than would be for host communities to better organize to ad- definitive. Whether the persons interviewed were aware dress the informational needs of immigrant retirees [3,23]. of or capable of judging care quality is another potential The median annual out-of-pocket medical cost was limitation. This is especially noteworthy because at least $5,250 for the Mexican sample and $1,650 for the some of the higher costs of health care in developed Panamanian sample. One explanation for the marked countries such as the U.S. and Canada are designed to difference could have included differences in health status, prevent low-incidence, high-impact adverse events, such as there was a nonsignificant trend for the Mexican as medication overprescribing [21] and the spread of sample to be older and more impaired (Table 1). Other antibiotic-resistant infections [33]. possible contributing factors could be more insurance coverage (e.g., because more of the Panamanian sample Conclusions were ex-military on Tricare) and Panama’s discount pro- The healthcare needs of retired U.S. citizens who choose gram for pensioners, which includes 15% off hospital to live abroad are likely to affect increasing numbers of charges and 20% off physician consultations [24]. older Americans in the future. Retirees living abroad report Virtually all interviewees reported a desire to see Medi- a host of dilemmas regarding gaps in services, healthcare care extended abroad. Unfortunately, the vast differences choices and insurance availability. Without attention from between the healthcare systems, the challenges experienced the policy, medical, and business communities, the problem by Tricare providing international coverage, and a desire of providing medical care to this growing population will by Medicare to contain expenses all mitigate against become increasingly urgent. this development [25-27]. Given the barriers to Medicare Competing interests extension abroad, feasible alternatives must be better The authors declare that they have no competing interests. developed to meet the needs of current and future emigrant Authors’ contributions retirees. Two attractive options are private insurance plans PDS had full access to all of the data in the study and takes responsibility for that focus on catastrophic expenses with high deductibles, the integrity of the data and the accuracy of the data analysis. Study concept and community risk pools [28,29]. Another option would and design: PDS, SZ, LWC. Acquisition of data: PDS, LWC, BEH. Analysis and interpretation of data: PDS, SZ, LWC, BEH. Drafting of the manuscript: PDS, SZ, be restructuring Medicare to provide cash payments and LWC, BEH. Critical revision of the manuscript for important intellectual content: medical savings accounts; such a program would be more PDS, SZ, LWC, BEH. Statistical analysis: LWC. Obtained funding: PDS, BEH. readily exported abroad but would provide inadequate Administrative, technical, or material support: LWC. Study supervision: PDS, LWC. Final approval for publication: PDS, SZ, LWC, BEH. All authors read and protection against catastrophic costs. Finally, it is possible approved the final manuscript. that financial pressures will lead Medicare to explore the cost-effectiveness of overseas programs for high-cost Acknowledgements patients, using research and demonstration waivers, as a Funding for this study was provided by the Elizabeth and Oscar Goodwin Endowment at the University of North Carolina at Chapel Hill and by the way of opening the door for Medicare payment abroad. Alpha Omega Alpha Carolyn L. Kuckein Student Research Fellowship. While it is far from clear how new health care options for U.S. retirees in Latin America will evolve, the increas- Author details Program on Aging, Disability, and Long-Term Care, Cecil G. Sheps Center ing internationalization of healthcare makes it highly likely for Health Services Research, University of North Carolina, Chapel Hill, that they will emerge [13]. In addition to the current and NC 27514, USA. Department of Family Medicine, University of North anticipated future growth of retirement abroad, the rapid Carolina, Chapel Hill, NC 27514, USA. The School of Social Work, University of North Carolina, Chapel Hill, NC 27514, USA. growth of medical tourism is a strong force encouraging system change [30,31]. As of 2008, 63 medical tourism Received: 27 December 2012 Accepted: 27 September 2013 companies were operating in the United States, the Published: 12 October 2013 Sloane et al. BMC Health Services Research 2013, 13:411 Page 8 of 8 http://www.biomedcentral.com/1472-6963/13/411 References 26. Knaul FM, Frenk J: Health insurance in Mexico: achieving universal 1. Casado-Díaz MA, Kaiser C, Warnes AM: Northern European retired coverage through structural reform. Health Aff 2005, 24:1467–1476. residents in nine southern European areas: characteristics, motivations 27. Xu K, Evans DB, Carrin G, Aguilar-Rivera AM, Musgrove P, Evans T: and adjustment. Aging Soc 2004, 24(3):353–381. 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Ginsburg JA, Doherty RB, Ralston JF Jr, Senkeeto N, Cooke M, Cutler C, et al: and take full advantage of: Achieving a high-performance health care system with universal access: what the United States can learn from other countries. Ann Intern Med • Convenient online submission 2008, 148:55–75. • Thorough peer review 22. Kane RL, Kane RA: What older people want from long-term care, and how they can get it. Health Aff 2001, 20:114–127. • No space constraints or color figure charges 23. Rowles GD, Watkins JF: Elderly migration and development in small • Immediate publication on acceptance communities. Growth Change 1993, 24:509–538. 24. Consulate of Panama: Panama Residency, Citizenship and Passports. [Cited October • Inclusion in PubMed, CAS, Scopus and Google Scholar 14, 2013]. Available from: http://www.consulatepanama.com/index.php/ • Research which is freely available for redistribution component/content/article/110-panama-residency-citizenship-a-passports.html. 25. Pauly MV, Zweifel P, Scheffler RM, Preker AS, Bassett M: Private health Submit your manuscript at insurance in developing countries. Health Aff 2006, 25:369–379. www.biomedcentral.com/submit http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png BMC Health Services Research Springer Journals

Health care experiences of U.S. Retirees living in Mexico and Panama: a qualitative study

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Springer Journals
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Copyright © 2013 by Sloane et al.; licensee BioMed Central Ltd.
Subject
Medicine & Public Health; Public Health; Health Administration; Health Informatics; Nursing Management/Nursing Research
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1472-6963
DOI
10.1186/1472-6963-13-411
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24119332
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Abstract

Background: Retirement migration from northern countries to southern countries is increasing in both Europe and North America, and retiree experiences will impact future migration and health services utilization. We therefore sought to describe the healthcare experiences and perceptions of retired U.S. citizens currently living in Mexico and Panama. Methods: 46 retired U.S. citizens (23 per country) who had been hospitalized (61%) or had a chronic health condition (78%) in two regions per country with large communities of retired U.S. citizens were identified. Detailed semi-structured interviews were conducted to explore experiences with, attitudes toward, and costs of healthcare. Interviews were analyzed using quantitative and qualitative methods. Results: Respondents averaged 68–70 years old, were well educated, had few physical dependencies, and had moderate incomes. They praised physician services as more personalized than in the U.S. and home care as inexpensive and widely available, expressed favorable opinions regarding outpatient and dental care, gave mixed ratings on hospital services, and expressed concerns about emergency services. Numerous concerns about health insurance were expressed, including the unavailability of Medicare and reductions in Tricare. Payment concerns and lack of data on local health providers made deciding where to obtain services challenging. Conclusions: Retirees living abroad report dilemmas regarding healthcare choices, insurance availability, and quality of care. As this population segment grows, pressure will increase for policy and business solutions to existing medical care challenges. Keywords: Retirement, Migration, Medical care, Mexico, Panama Background warmer climate, lower living costs, and a desire to Trans-national migration of retirees is an increasingly experience another culture [1,2,4,5]. common phenomenon in Europe and the United States. As of 2011, an estimated 6.32 million non-military The common European pattern involves retirees from American citizens lived overseas, about half of whom northern countries such as Germany, the Netherlands, live in the Western Hemisphere [6]. Of these, a significant Great Britain, Norway, and Sweden relocating to southern and increasing proportion are retirees living in Latin countries such as France, Italy, Spain, and the Canary America, with Mexico and Panama currently being the Islands [1]. In the Western hemisphere, a similar pattern most popular destinations [2,3]. In 2012, the U.S. Social has evolved, with Canadian and U.S. citizens increasingly Security Administration reported that nearly 360,000 selecting retirement destinations in Latin America [2,3]. retired workers were receiving benefits abroad, a 20 Reasons most commonly offered for migration include percent increase since 2007 [7]. With the upcoming retirement of over 100 million U.S. “baby boomers” in the next 30 years, many of whom have limited retirement * Correspondence: philip_sloane@med.unc.edu savings and an increasing number of whom are consider- Program on Aging, Disability, and Long-Term Care, Cecil G. Sheps Center for Health Services Research, University of North Carolina, Chapel Hill, ing non-traditional retirement alternatives, the number of NC 27514, USA U.S. citizens retiring in Latin America has been projected Department of Family Medicine, University of North Carolina, Chapel Hill, to mushroom [5,8]. NC 27514, USA Full list of author information is available at the end of the article © 2013 Sloane et al.; licensee BioMed Central Ltd. This is an open access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Sloane et al. BMC Health Services Research 2013, 13:411 Page 2 of 8 http://www.biomedcentral.com/1472-6963/13/411 Health care is an important issue for older persons; participants, and study procedures were approved by however health care issues among retirees who migrate the Institutional Review Board of the University of North abroad have received relatively little attention in the Carolina. Ethical approval was not obtained from Mexican retirement migration literature [1]. For European migrants, and Panamanian authorities since only U.S. Citizens medical care is usually reimbursed by national health participated in this research. No Mexican or Panamanian insurance plans that pay for emergency and planned nationals were involved in any way in the subject accrual treatment anywhere in the European Union [9]; however or data collection. satisfaction with services has been reported to be mixed [10], and major health events can be unusually disruptive Data collection [11]. For U.S. migrants, the issue of healthcare abroad Interviews in Mexico were conducted in March 2007 and is even more challenging, as neither Medicare (the in Panama in June and July of 2008; all except for one were government health insurance for senior citizens) nor conducted in person, and all were audiotaped and tran- most private health insurance plans cover expenses scribed for analysis. Each interview lasted approximately incurred in other countries [12-14]. Therefore, how 45 minutes and followed a semi-structured format. Topics retired U.S. citizens living abroad manage their healthcare addressed included: is a particularly important issue [2,8,15,16]. Given the anticipated growth in retirement migration  personal health and resources (e.g., functional status; to Mexico and Central America, information about the activities of daily living; health status; health actual experiences of retirees who have required healthcare insurance); while living abroad would help inform personal, corporate,  healthcare experiences while living abroad and policy decisions regarding international retirement. (e.g., chronic illness care, serious acute problems, Therefore, to learn more about the healthcare experiences hospitalizations); and needs of U.S. retirees living abroad, we conducted and  payment for medical care (e.g., out-of-pocket expenses; analyzed semi-structured interviews of retirees in Mexico cost of specific incidents such as hospitalizations or and Panama who had used local healthcare resources for trips back to the U.S. for health care); acute hospital care, chronic illness management, or both.  opinions about the quality, availability, and cost of healthcare in the host country (e.g., desires in a Methods health care provider; experiences with providers in Participants and recruitment the U.S. and Latin America; whether or not they In each country, two regions with large numbers of had ever postponed care and if so why); expatriate American retirees were targeted for recruitment,  future health care plans (e.g., what they would do using a purposive sampling approach. In Mexico, re- if they had a serious illness or needed long-term cruitment was carried out in San Miguel de Allende and care services); and Chapala, both of which are medium-size communities  comparison and contrast with the United States within an hour and a half of large cities. In Panama, (e.g., experiences with health professionals; cost). recruitment focused on Panama City, the capital, and Boquete, a rural region in the north. Participants were Interviews were conducted by trained research assis- recruited using notices in English and bilingual newspa- tants with experience in qualitative data collection and pers, postings to local expatriate blogs and list serves, health services research, who were encouraged to pursue networking with expatriate societies, and acquaintances themes that arose and seek clarification as required. of respondents. Our goal was to interview retirees who required sig- Data analysis nificant use of the local healthcare system. Therefore, Data analysis was conducted using a grounded theory participants had to be: native born U.S. citizens who were approach [17]. The first step involved developing codes retired, aged 55 or older, had lived full-time in Mexico or based on the content of each phrase, sentence or para- Panama for at least a year, and either have a history of graph. This was done by four coders from different hospitalization in Mexico or Panama during the previous disciplines (medicine, social work, and psychology) who two years or have a chronic illness requiring ongoing compared and agreed on a final list of codes. Next, the medical management and monitoring. team members independently coded the transcribed Of 49 eligible volunteers, three were not interviewed, interviews for manifest and latent themes, as outlined by two because the interviewee did not keep the appointment Padgett [18]. and one who withdrew due to hearing difficulty. The final Quantitative data were imported into SAS 9.1® and sample included 23 respondents from Mexico and 23 from checked for accuracy and logical errors, with discrepan- Panama. Written informed consent was obtained from all cies resolved by reference to the transcribed interview. Sloane et al. BMC Health Services Research 2013, 13:411 Page 3 of 8 http://www.biomedcentral.com/1472-6963/13/411 Frequencies and averages were computed, and analyses the facilities adequate. Hospital physicians largely spoke compared frequencies and distributions of responses by English, and many (especially in Panama) had some U.S. country. Continuous data were analyzed for significance training. Many respondents remarked that the hospital using the t-test option in SAS 9.1®; categorical data were staff provided more time and personalized attention than analyzed using the Chi-Square test or, as appropriate, they had experienced in the U.S. One reported that the Fisher’s Exact option. “doctors are not frantically busy like they are in the United States,” and several commented about nursing Results care being more attentive. A few respondents in Mexico Study respondent characteristics are displayed in Table 1. reported choosing to use the public hospital system (the The mean age was 69.9 for the Mexican respondents Instituto Mexicano del Seguro Social [IMSS]), which can and 68.1 for the Panamanian respondents, with the range be purchased by immigrants after a waiting period. IMSS from 59 to 87. The majority were married, had a college hospitals were reported to have less access to technology degree, had few dependencies in daily activities, and had than U.S. hospitals, however, and patients were expected some Spanish proficiency. Reported income levels were to be accompanied by someone who would attend to moderate, with approximately half reporting monthly personal care needs. incomes below $3,000. Twenty-eight respondents (61%) For specialized procedures, residents in smaller commu- had been hospitalized in Mexico or Panama, and 36 (78%) nities reported having to travel to larger centers, occasion- reported a chronic illness that required ongoing care and ally at considerable cost or hardship. One respondent, for monitoring. In general, the two samples did not differ sig- example, had to move from Boquete to Panama City for nificantly in demographic or health status characteristics, two months to receive daily radiation treatments. except for greater reported income and fewer white Persons with Medicare often expressed a desire to go respondents in the Panamanian sample. back to the U.S. for hospital care, some citing quality In qualitative analyses 38 open codes were developed, and all citing cost. The risk of delaying care and the reflecting four overarching themes: availability, quality cost of travel were cited as significant drawbacks to and cost of care; relationships with providers; paying for this strategy, however; one reported spending $13,000 healthcare; and making healthcare choices. to return to the U.S. by private Lear jet during a health emergency. Availability, quality and cost of care A unique aspect of Panamanian healthcare is the avail- Both Mexico and Panama have parallel public and private ability of a military hospital in Panama City. Unfortunately, healthcare systems, with the overwhelming majority of veterans in our sample reported problems communicating interviewees using the private system exclusively or most of up the chain of command, because they often had to the time. Opinions about quality were mixed but generally contact the U.S. to determine whether a given service favorable regarding access, visit length, price, and commu- was covered by their benefits. As one military retiree nication. Negative reports focused on uneven expertise, noted, “There’s no local direct contact with the VA or language difficulties, acute care costs, and less available Department of Defense or anybody who can give us technology. information….They give us a phone number we can call… (and) there is a whole lot of time involved in trying to com- Outpatient care municate by telephone. We get a lot of menus. Sometimes Most respondents used the private system for outpatient we don’t get an answer at all.” care, reporting easy access to physicians and generally praised the services received. A pervasive theme involved doctors providing longer Emergency services appointments and more personal service than their U.S. Respondents in both Mexico and Panama described counterparts. As one respondent commented: “You can emergency services as needing improvement, particularly get an appointment with a specialist, and for 500 pesos in regard to transport and paramedic care. As one re- they will give you an hour or more of their time, give you spondent noted, “what they call paramedics down here are their cell phone number, and return your emails.” Mental not paramedics; they strictly transport you to the hospital. healthcare was reported to be less developed than in the They cannot administer drugs….Their first aid training is U.S., however, and record-keeping was viewed as uneven very basic, and they have no requirement to get annual and often inferior. updates.” The availability of blood supplies in the event of an emergency was also cited as a cause for concern. Hospital services However, efforts were reportedly being made to improve Nearly all respondents reporting hospitalization had used emergency services in both countries, often with assistance private hospitals and reported the quality to be good and from retirees or U.S. based physicians. Sloane et al. BMC Health Services Research 2013, 13:411 Page 4 of 8 http://www.biomedcentral.com/1472-6963/13/411 Table 1 Characteristics of study participants Demographic characteristics Mexico (n = 23) Panama (n = 23) P-value for difference Mean (SD) Range Mean (SD) Range Age 69.9 (6.8) 59.0 – 87.4 68.1 (4.5) 60.8 – 80.6 0.40 Years living in Mexico or Panama 7.2 (5.6) 1.0 – 20.0 6.4 (12.2) 0.6 – 60.6 0.78 Spanish proficiency (0 = none to 10 = native) 4.7 (2.3) 0.0 – 9.0 4.2 (2.4) 0.5 – 8.0 0.51 N%N% Gender (female) 15 65.2 8 34.8 0.08 Race (White/Caucasian) 23 100 18 78.3 0.05 Marital status 0.29 Married 14 60.9 17 73.9 Widowed Separated/divorced 6 26.1 5 21.7 Never married 3 13.0 1 4.4 Education 0.13 High school or less 3 13.0 0 0.0 Some college 2 8.7 8 34.8 College degree 4 17.4 4 17.4 Post-graduate degree 14 60.9 11 47.8 Income (monthly) 0.04 $1,000-$1,999 6 26.1 2 8.7 $2,000-$2,999 8 34.8 8 34.8 ≥ $3,000 9 39.1 13 56.5 Medical and functional characteristics N % N % Hospitalized in Mexico or Panama during prior 2 years 11 55.0 17 73.9 0.22 Days hospitalized among participants hospitalized [Mean (SD), Range]* 4.9 (4.8) 1 – 17 3.3 (1.6) 1 – 6 0.36 Had a chronic illness requiring ongoing care 17 77.3 19 82.6 0.72 Requires supervision or assistance with: Feeding self 1 4.3 0 0.0 0.48 Walking a block 2 8.7 3 13.0 0.67 Dressing self 2 8.7 0 0.0 0.09 Bathing self 2 8.7 0 0.0 0.09 Using telephone 1 4.3 0 0.0 0.22 Shopping for groceries 2 8.7 0 0.0 0.14 Reliably taking medications 1 4.3 0 0.0 0.19 Handling finances 1 4.3 0 0.0 0.43 Depression 3 13.0 2 8.7 0.61 Incontinence 3 13.0 2 8.7 0.61 Number of medications [Mean (SD), Range] 4.9 (2.8) 2 – 12 4 (3.3) 0 – 10 0.39 *Outlier of 75 days removed from Mexican dataset; with outlier, mean (SD) = 11.9 (22.6), p < 0.01. Long-term care them as friends and knowing their entire family. As a In both countries home care was reported to be widely result, a common theme among many respondents was available, inexpensive, and of high quality. “Where I live, of planning to remain at home with services until they I can get a nurse to take care of me 24 hours a day for died. about $20 to $25 a day,” one respondent said. Several Few respondents knew about the availability of institu- employed full-time home care aides, often referring to tional long-term care. Some had not given it much thought. Sloane et al. BMC Health Services Research 2013, 13:411 Page 5 of 8 http://www.biomedcentral.com/1472-6963/13/411 Others, especially those with close ties to children in the communication with nurses and ancillary care providers, states, reported that they would return to the U.S. if they most of whom spoke only Spanish, was often perceived needed long-term care. as a challenge. “Language is a problem, particularly with the nurses or attendants or receptionists,” was a typical Dental care comment. Dental services in both countries were widely praised for high quality and low cost, except in rural Boquete where Paying for healthcare it was less available. Comments included “I know a lot of Healthcare costs were universally described as lower than people who come to Mexico regularly to get their dental in the U.S. However, virtually all interviewees expressed care,” and “you wouldn’t get a cleaning in the U.S. any- concern about lack of health insurance coverage in where near the quality of this.” general, and the unavailability of Medicare in particular. The reported median annual out-of-pocket expenditure Medication was $5,250 for the Mexican sample and $1,650 for the Respondents in both countries reported that most Panamanian sample. A few reported much higher out-of- medications other than narcotics were available with- pocket costs and several expressed concern about losing out prescription. They tended to appreciate the easy their savings from a high-cost illness or hospitalization. access, but some reported concern about potential use The experience of one interviewee illustrates this dilemma: of unnecessary or contraindicated medications. Costs “Last January I was involved in a car accident where I was varied and were reported to be increasing. As a result, hit by a bus. The police officer at the scene told the people interviewees with U.S. insurance often waited to refill there that if I could afford it, to send me to (a private medications during periodic visits to the States or bought hospital) because my chances of survival there are going medications online, processes that could complicate deliv- to be a lot better than my chances at the (public) hospital…I ery. As one reported: “We buy [medications] from Canada was in the hospital for two and a half months. The hospital on the internet because they are cheaper…Canada can’t stay cost $320,000 (U.S. dollars).” send them to Mexico, so we have to find someone in the U. Reliable, comprehensive, reasonably-priced local in- S. who is planning to come down…in four to six weeks, and surance plans appeared to be largely available. Most give them plenty of time to send it to the wrong place, not common were limited private plans from a local hospital to be delivered, or to be sent back for us to spend time on or medical group. One was described in this manner: “ I the internet and the telephone trying to find them, have don’t have a real health insurance policy … Ihave a very them sent back again, and have the person get them in limited HMO with a local group of doctors in [nearby city] time before they leave.” that is…very inexpensive … like maybe $200 a year… If we can find someone in that group, then we will get a discount.” Relationships with providers Retirees in Mexico can purchase IMSS insurance after Generous personal attention from healthcare providers a waiting period for approximately $300 U.S. dollars was a common theme of respondents in both countries. per year; however, the public system was described as One respondent said, “they spend a good half hour, confusing and many voiced concerns about quality. 45 minutes with you….It’s not like in the states where you Some respondents had state employee or corporate go to see your GP and if he spends 10 minutes with you, policies from the U.S. that extended benefits overseas; you’re fortunate.” Physicians were commonly reported to their reported reimbursement and satisfaction varied. One “go that extra mile” by giving out cell phone numbers stated, for example: “The insurance only paid about $175 and email addresses, making house calls, communicating of that $1,000 (hospital charge).” with other providers, negotiating payment arrangements, Military retirees universally complained about Tricare, even personally driving patients home or to the hospital. the U.S. military health insurance program. Until recently, One respondent characterized his care as “just the old, coverage for military retiree healthcare costs was available long-before-you-were-born style of medicine.” Respondents worldwide and considered excellent. However, recent also praised the dedication and quality of care received reductions in payment schedules and long delays in from home care providers. reimbursement have caused many healthcare providers In rare cases reports were less favorable. One inter- to no longer accept Tricare. One interviewee explained, viewee reported being “not totally thrilled with the way “Let’s say a doctor charges you $100 for a visit. He submits he [neurologist] acts towards us,” explaining that the his bill to Tricare. Tricare says, we’re only going to pay him physician was less respectful than her doctor in the U.S. $30, and of that $30, they are only going to pay 75%.” The This concern prompted her to consider returning to the U. result has been more expatriate retirees seeking care in S. for healthcare. In addition, though interviewees reported the U.S. or Puerto Rico, a process that is not always widespread availability of English-speaking physicians, practical and can lead to risky delays. One interviewee, Sloane et al. BMC Health Services Research 2013, 13:411 Page 6 of 8 http://www.biomedcentral.com/1472-6963/13/411 for example, had recently attended the funeral of a friend When asked about long-term care, the younger and whose Panamanian hospital stopped accepting Tricare healthier retirees often reported not giving it much thought. for his dialysis, and who subsequently died while awaiting Typical responses were “Ican’t really decide on that acceptance for care at a U.S. military hospital. because I don’t know what turn my health will take” Retirees who qualified for Medicare were universally and “I would just have to evaluate where we are at that upset about the lack of coverage. Many felt indignation point.” Those who had thought about the issue fell into at having to continue to pay a monthly fee for Part B two groups: those who would opt to be near family in coverage to avoid the risk of higher premiums if they the U.S., and those who would stay abroad and obtain later returned to the U.S.. Every interviewee wanted to in-home services. One respondent replied: “I’d stay right see Medicare benefits extended to retirees living abroad, where I am. I would find someone who would come in many of whom believed that the U.S. would gain financially every single day or overnight depending on what I need, from paying for less expensive services abroad. “It’s just and I would be able to afford it.” costing the U.S. government more and more to have us come back, especially for basic stuff,” one commented. Discussion The population of retired U.S. citizens living abroad is growing and is projected to mushroom in the coming Making healthcare choices years [2,3]. Because healthcare provision for retirees living No respondent in the Mexican sample spoke of having abroad is a common concern and has undergone little chosen to locate there for healthcare reasons. In contrast, systematic investigation, we interviewed retired U.S. citizens the availability, quality, and cost of healthcare were a in Mexico and Panama who had significant healthcare consideration for a number of interviewees in Panama, needs. Our interviews identified many strengths regarding which is booming as a medical tourism destination and health services in those countries, including lower costs, has several hospitals that offer insurance plans catering availability of high quality services, personalization of care, to U.S. retirees (including one in Panama City that is and in-home care. Many problems were also identified, in- affiliated with Johns Hopkins University). Moving abroad cluding concerns about consistent quality, reduced access for healthcare reasons was particularly true for retirees in to technology, decision-making challenges, inadequate their late 50s and early 60s who had not yet qualified for insurance coverage, and a desire to see Medicare extended Medicare, and for military veterans who were drawn by abroad. the existence of military healthcare in Panama. As is typical of Latin America, parallel public and private Regardless of the role of healthcare in decisions to retire healthcare systems exist in Mexico and Panama. The public abroad, virtually all interviewees described the task of systems tend to focus on the uninsured poor (though deciding where and how to obtain services as challenging. attempts to provide universal coverage are growing); Contributing to this problem were not only the insurance resources are limited; and service quality is highly variable issues described previously, but also the relative unavail- [19]. Persons with adequate resources, whether U.S. citizens ability of consumer information. One respondent spoke of or natives, tend to selectively utilize the private system having comparison shopped for the best hospital to have because of its reputation for higher quality, efficiency, prostate surgery in Dallas, using published statistics on and highly personalized care [20], as did the vast majority complication rates and patient satisfaction, and finding of our interviewees. Our respondents’ comments were no similar information available in Mexico. As a result, strikingly similar to those of Mexican immigrants to the most retirees depended largely on informal information U.S. who return to Mexico for health care in the private gathered by word-of-mouth, expatriate organizations, system – that doctors provide more personal care, providers they had already met, and internet list serves providers appear less motivated by money, and things can and blogs. get done faster [20]. Respondents who had Medicare reported weighing the Indeed, a particularly striking theme from our interviews costs of deductibles, co-pays, travel, and demands on was high satisfaction with physician providers, who were informal caregivers when determining where and how to often favorably compared with those in the U.S. Inter- access services. Some maintained a house or apartment in viewees frequently reported providers taking a personal the U.S. and returned regularly, in part to obtain medical interest in patients, routinely providing long appointments, services. Those who did not have a U.S. home base had and being readily available. Possible contributing factors higher travel costs. As one noted, “you have to pay for a could include true international differences in practice style place to stay, food, you’ve got to rent a car, airfare, and or differential treatment of U.S. retirees, perhaps in part then (hospitals) only keep you for a nano-minute…So the because they pay privately. Whatever the explanation, question is, do you go back or do you stay here and just this finding is in contrast to U.S. healthcare, which, in cross your fingers?” comparison of health systems in six developed countries, Sloane et al. BMC Health Services Research 2013, 13:411 Page 7 of 8 http://www.biomedcentral.com/1472-6963/13/411 was rated among the lowest in patient-centeredness, majority of which had been founded after 2004 [31]. In access, and efficiency [21]. Home care was another area of response to this trend, moves to provide better assurance high satisfaction, with many respondents extolling the of care quality are growing. For example, Joint Commission ready availability of high quality, affordable providers. International, an extension of the main U.S. healthcare Considering that the vast majority of U.S. seniors would accrediting agency, currently accredits seven hospitals and prefer home-based services to institutional long-term care, health systems in Mexico and two in Panama [32]. the existence of inexpensive quality home care could Major limitations of the study include the purposive constitute a significant attraction for retirement to Mexico nature of the sample and the respondents’ limited ability or Panama [22]. to judge issues related to quality of care received. Since Difficulty choosing where and from whom to obtain no census of retirees exists, the sampling method we care was widely reported, with retirees needing to network used is typical of that employed in interview studies of extensively to make choices. In particular, a lack of available migrant retirees [5,10]. Such a method limits drawing public data on provider credentials, quality, and outcomes generalizations from results, however, so our conclusions was noted. This situation is easily remedied; one solution should be considered hypothesis-generating rather than would be for host communities to better organize to ad- definitive. Whether the persons interviewed were aware dress the informational needs of immigrant retirees [3,23]. of or capable of judging care quality is another potential The median annual out-of-pocket medical cost was limitation. This is especially noteworthy because at least $5,250 for the Mexican sample and $1,650 for the some of the higher costs of health care in developed Panamanian sample. One explanation for the marked countries such as the U.S. and Canada are designed to difference could have included differences in health status, prevent low-incidence, high-impact adverse events, such as there was a nonsignificant trend for the Mexican as medication overprescribing [21] and the spread of sample to be older and more impaired (Table 1). Other antibiotic-resistant infections [33]. possible contributing factors could be more insurance coverage (e.g., because more of the Panamanian sample Conclusions were ex-military on Tricare) and Panama’s discount pro- The healthcare needs of retired U.S. citizens who choose gram for pensioners, which includes 15% off hospital to live abroad are likely to affect increasing numbers of charges and 20% off physician consultations [24]. older Americans in the future. Retirees living abroad report Virtually all interviewees reported a desire to see Medi- a host of dilemmas regarding gaps in services, healthcare care extended abroad. Unfortunately, the vast differences choices and insurance availability. Without attention from between the healthcare systems, the challenges experienced the policy, medical, and business communities, the problem by Tricare providing international coverage, and a desire of providing medical care to this growing population will by Medicare to contain expenses all mitigate against become increasingly urgent. this development [25-27]. Given the barriers to Medicare Competing interests extension abroad, feasible alternatives must be better The authors declare that they have no competing interests. developed to meet the needs of current and future emigrant Authors’ contributions retirees. Two attractive options are private insurance plans PDS had full access to all of the data in the study and takes responsibility for that focus on catastrophic expenses with high deductibles, the integrity of the data and the accuracy of the data analysis. Study concept and community risk pools [28,29]. Another option would and design: PDS, SZ, LWC. Acquisition of data: PDS, LWC, BEH. Analysis and interpretation of data: PDS, SZ, LWC, BEH. Drafting of the manuscript: PDS, SZ, be restructuring Medicare to provide cash payments and LWC, BEH. Critical revision of the manuscript for important intellectual content: medical savings accounts; such a program would be more PDS, SZ, LWC, BEH. Statistical analysis: LWC. Obtained funding: PDS, BEH. readily exported abroad but would provide inadequate Administrative, technical, or material support: LWC. Study supervision: PDS, LWC. Final approval for publication: PDS, SZ, LWC, BEH. All authors read and protection against catastrophic costs. Finally, it is possible approved the final manuscript. that financial pressures will lead Medicare to explore the cost-effectiveness of overseas programs for high-cost Acknowledgements patients, using research and demonstration waivers, as a Funding for this study was provided by the Elizabeth and Oscar Goodwin Endowment at the University of North Carolina at Chapel Hill and by the way of opening the door for Medicare payment abroad. Alpha Omega Alpha Carolyn L. Kuckein Student Research Fellowship. While it is far from clear how new health care options for U.S. retirees in Latin America will evolve, the increas- Author details Program on Aging, Disability, and Long-Term Care, Cecil G. Sheps Center ing internationalization of healthcare makes it highly likely for Health Services Research, University of North Carolina, Chapel Hill, that they will emerge [13]. In addition to the current and NC 27514, USA. 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