There is usually more than one way to treat a condition, but most patients only ever see one. The plan arrives as a single option, with the diagnosis and recommended course presented together. Whatever alternatives the doctor considered along the way tend to stay with the doctor.
One case in Bangkok this year shows how much difference those other options can make. A LUMA member with health insurance in Thailand providing 5 million baht of annual cover was unfortunately diagnosed with cancer.
The private hospital treating the member proposed a treatment plan running over two years, estimated at about 14 million baht. With the policy providing 5 million baht a year, or 10 million baht across the two policy years, the member would have had to self-fund the remaining 4 million baht to go ahead with the treatment.
The member contacted LUMA, which immediately put them in touch with Medipro, an international medical team, to review the case. After studying the case, Medipro’s doctors contacted the member and, with their approval, referred them to a specialist at Chulalongkorn Hospital.
There, the same treatment plan over the same two years was estimated at about 7 million baht. It fell within the coverage, and nothing had to be self-funded.
The plan itself did not change. It used the same medicine over the same two years, with doctors of the same qualifications and expertise. What changed was where it would be delivered, and that difference decided whether the member would have to pay 4 million baht out of their own pocket.
The first plan is one option, not always the only one
In many cases, there is more than one reasonable route. Open surgery and keyhole surgery, for example, may reach the same outcome through very different recoveries. Two medicines can treat the same condition and leave the patient with quite different side effects.
For some conditions, watchful waiting is a real option. This does not mean doing nothing. It means having a plan with review dates, agreed tests and a clear point at which treatment should begin.
A person can also sometimes start in one department when another speciality would have been better suited, simply because of which doctor they happened to reach first.
None of that makes the first plan wrong, and most of the time it is not. But a patient can only take part in the decision if they clearly know what the alternatives were. A decision like this involves recovery, risk and quality of life as much as it involves medicine.
Dr Gerard Lalande is a French-trained physician who has worked in Southeast Asia for more than 30 years. He is a founding member of Medipro, an independent international medical advisory team that follows international medical standards and gives his insight on what that difference can mean for patients.
“Primum non nocere. First, do no harm,” he says. “That has never meant avoid treatment. It means the expected benefit of what we do has to outweigh the risk of doing it, and it has to hold for this patient rather than for patients in general. The same diagnosis in a 40 year old and in a 70 year old is not the same decision.”
Patients are often asked to choose a path without ever seeing the full picture. That can mean deciding whether to start treatment now, which treatment plan to accept and even where to get it.
For expats, it can be harder still. There is not always one GP or family doctor holding the full medical history, and records can be spread across hospitals, clinics and even countries. That often leaves the patient as the only person who knows the whole story, which is a great deal to carry while also being unwell.
“We do not refer to hospitals,” Dr Lalande says. “In any hospital, anywhere, experience varies from one doctor to the next. We want to make sure that our client falls into the arms of the right doctor whom we trust.”
Timing is what makes this useful. A second opinion is meant to be used while the options are still open, before a patient has agreed to a treatment plan and before treatment has started.
A second medical opinion gives the member another expert view before they start treatment. It can confirm the diagnosis, explain the first plan and show any other good options. Some hospitals may not give patients the time needed to seek one, and this can affect the member directly.
Medipro helps the member speak to the right specialist for their case, often someone more experienced in that exact condition. At the very least, it is a doctor of equal level, so the member can compare the advice given by the first and second specialists.
LUMA and Medipro do not decide what the member should do. They provide review and access to expertise, and the choice always stays with the member.
The part of the system most expats never see
Thailand is well known as a medical destination, largely because of its international private hospitals, and they have earned that reputation. They are built for international patients and operate in English, often in Japanese or Chinese too. Appointments are usually available quickly, and for many health issues they are the right choice.
Alongside them are Thailand’s academic hospitals, which train many of the country’s specialists and where many great senior doctors and professors still practise. In Bangkok, they include Siriraj, King Chulalongkorn Memorial and Ramathibodi.
For many Thai families, these are the hospitals they would choose for serious or specialist care. That is not because they are looking for the cheaper option, since many can afford to go almost anywhere. They go for the reputation of the doctors and professors who work there.
“People come to Thailand for the private hospitals, and the management of care they find there is good,” Dr Lalande says.
“Good care at private hospitals starts earlier in the system. Teaching hospitals train the specialists, and many of the senior doctors who trained them still see patients. For patients, it often matters more to find the right doctor (and where they see patients) than to choose a hospital name.”
Many of those professors also hold clinics at the large international hospitals, so the same doctor may be available in more than one place, sometimes at a different price and after a different wait. Choosing a hospital does not settle who will actually treat you.
The academic hospitals also offer a depth that is harder to find elsewhere. Several specialities work under one roof, so a complicated case is more likely to be reviewed by more than one doctor. Difficult cases are referred there as well, so their doctors tend to see rare and complex conditions more often than colleagues elsewhere.
Expats rarely find their way there, for reasons that are practical rather than medical. Thailand’s universal coverage scheme, often called the gold card, is for Thai nationals. Social security is generally accessed through employment, requires a work permit and is tied to particular hospitals within the system.
Academic hospitals can also feel harder to reach because of the registration process, with much of the administration in Thai. An appointment with a particular specialist may take weeks or even months. As a result, many expats only ever see the part of the health system designed for international patients.
Access has improved, though. Many academic hospitals now run private wings where patients book an appointment instead of queueing early in the morning, and where they can see the same consultants who teach and practise in the main hospital. What has not changed is that somebody still needs to know which consultant to ask for.
For Dr Lalande, the point is getting the right treatment at the right time, in the right place. “Money is rarely the real issue,” he says. “It’s that foreign patients often don’t have the local knowledge to navigate the system, to know which specialist to ask for and where to find them.”
Four questions worth asking
What happens if I wait three months? This helps separate a condition that needs treating now from one where there is time to think and compare.
What are the other options, and why is this one better for me? This asks for the reasoning behind the recommendation. If there is only one sensible option, that is useful to know too.
Do you see patients anywhere else? Many senior consultants hold clinics at more than one hospital. Seeing the same doctor in a different place can mean a different waiting time or a different price.
Can I get a second medical opinion? For anything serious, this is normal practice rather than a challenge, and a doctor who is confident in the diagnosis will usually help arrange it. For LUMA members, a second medical opinion through Medipro is a complimentary service that comes with their health insurance plan.
* Dr Gerard Lalande graduated from Paris XIII Medical School, France, with advanced diplomas in tropical medicine, emergency medicine, aeronautical medicine and statistics applied to medicine. He has worked across Southeast Asia for more than 30 years, coordinating complex medical cases throughout the region. He is a founding member of Medipro and chief medical officer at LUMA, which provides health insurance in Thailand and across Southeast Asia for expats and their families.
The story A second medical opinion halved the cost of this cancer treatment without changing the plan as seen on Thaiger News.
