August 14, 2018

Why Are We Losing Patients to Tijuana?

For several decades, our nation has been the destination of choice for Saudi princes and other top one percenters when they need cardiac or cancer care.

But medical tourism is no longer for the rich. It’s a booming industry being driven by a new patient…and those patients are your patients.

In 2014, 1.25 million Americans left our nation to get health care. There are about 43,000 zip codes in the United States. By simple division, that averages to 29 patients per zip code who have bypassed their home health systems to seek help abroad.

This begs the question: if your health system lost 29 joint replacement or bariatric surgeries a year, how would that impact your organization’s bottom line?

Ask the leaders of these service lines and they’ll tell you it hurts. But how and why is this really happening and what does it all mean beyond these service lines?

What are our patients telling us about the way we provide access to care?

The answers are simple. These new patients are firing a warning shot across the bow of health system’s everywhere. This new patient has grown intolerant with bureaucracy, costs and the hurdles they must overcome to access medical care.

They’re mad as hell. They’re distrustful of another American institution and they’re empowered to do something about it. So who are these new patients?

To find out, let’s meet Sarah, one of the more than 1.25 million people who went abroad for care this year.


Ironically, Sarah’s story begins in a galaxy far, far away. A few weeks ago, I was in my study in Richmond playing Star Wars Battlefront online with my friend Rob, who lives 1300 miles away. As we talked on our headsets, laughing at ourselves and blasting Stormtroopers, we caught up with the happenings in each other’s lives.

My friend boasted that he could get away with playing all night because his wife was out of town. When he gave a cryptic reply as to her whereabouts, the reporter in me pressed him.

“Well it’s supposed to be a big secret but she’s in Tijuana with our son right now getting bariatric surgery,” Rob finally admitted.

(Note: In order to protect both of our lives, I have published this story only under the agreement that I would not reveal anyone’s real identity.)

My rebel soldier went down in a hail of laser fire as I lost my concentration thinking about Sarah going under the knife in Tijuana.

Rob understood my own barrage of questions that followed. Beyond the headlines depicting Mexico as a narco war bloodbath (the State Department continuously issues travel warnings to the Tijuana region specifically), Rob and I both had an idea of what Tijuana was like.

Both Rob and I had at one time been Marines just across the border in Camp Pendleton. We both recall that Tijuana was often included in the “No-Go” list. This is an order that was read aloud by our commanding officer before they released us for the weekend. In other words, if you went to Tijuana and they found out about it, whatever unpleasantries you survived to get back to base would probably pale in comparison to the yoke of military justice that awaited you.

Of course, as even the most amateur psychologist might tell you, telling a group of testosterone-charged, young males where not to go is actually a surefire way to drive your audience directly to said forbidden locale.

In short, “some of us” have been to Tijuana and it’s the last place one would think of to send your wife to get surgery. So who would do this and why?

I know these people. They’re not crazy.

These are educated, intelligent, gainfully employed and commercially insured people—they’re ordinary middle-class Americans.

Ordinary that is, until now. This family became extraordinary when they chose to become medical tourists.  But the reasons they made this choice reflect the feelings that many everyday patients harbor about the American way of health care.


In a series of discussions in the weeks that followed, I followed Sarah’s journey.

Sarah and Rob met online about 15 years ago as both were active gamers. At Franklin Street, we use patient personas to bring targeted groups of patients alive to market service lines like bariatric surgery. Sarah nearly perfectly fits our persona called the Gradual Gainer.

In this persona, rather than someone who was morbidly obese or gained weight very suddenly, the Gradual Gainer may only add a few pounds every year. But after a few decades, this person can be surprised as to how much weight they have gained over the years. The Gradual Gainer actually represents the largest section of Americans who are overweight.

Sarah and Rob’s son, Tony, was closer to the Lifelong Struggler persona. This is someone who has struggled with weight their entire life. At the extreme, they’re always the last kid picked for kickball at recess.

Only in his 20’s, Tony was already on a slew of medications. Sarah was tired of the self-esteem wars her weight was waging against her. When dieting and exercise weren’t doing enough, mother and son decided to take action. Together, they began to explore the option of bariatric surgery.

Here’s where the story gets scary for healthcare marketers. 

They never even bothered to seriously consider their home health systems. What is most shocking is that Rob and Sarah live in close proximity to some of the best health systems in our nation.

Their initial online research and stories from family and friends painted a picture they didn’t want to be depicted in.

“The red tape we kept hearing about was ridiculous. The costs didn’t seem to make sense either. We’re told about the long term costs of being overweight but insurance companies and hospitals obviously don’t see it that way,” Sarah said.

Working with health systems, I know that the bariatric surgery process is not user-friendly. A missed appointment in the pre-surgery phase (even if you are ill) can result in being kicked out of the program. This phase is long, tedious and obstructive when you are in the patient’s shoes. One health system we recently collaborated with was proud of their 35 percent graduation rate from their bariatric program.

Rob brought a more direct view, “Yeah, it’s no surprise where the interests of the insurers are. Or the hospital’s. I guess neither see the money in it so they don’t care. We said screw them then, let’s find another way.”

Now is where the consultant in me must pause and of course recognize that some of this is unfair from the health system’s point of view. You know the pressures of reimbursement, regulations and the role of payors more than anyone.

But hear this: your patients don’t care about your problems.

As American confidence in bedrock institutions like banks, large corporations, the media and our government become symbolic of national distrust, it’s very easy for the bureaucracies of hospitals and their allied insurers to be lumped in with them—however fair or unfair that may be.

So Sarah, Rob and Tony did their research and discovered an entire subculture of people just like them who said, “Screw the hospitals and insurers.”


From Facebook pages to Reddit forums and online clearinghouses of obesity treatment information, suddenly a world of options opened up to them. And many of those options were south of the border.

Obesity Coverage is one of many websites that guide patients through their options for treatment in Mexico. Note the copy, where they position these procedures as “life saving” yet note that insurance coverage can be hard to come by.

My online research also took me into the depths of Reddit, where I conversed with several other patients.

Of course, online reviews and faceless endorsements can be sketchy. So Sarah found real people to ask about surgery in Mexico.

She didn’t have to look far.

Remember those 29 people in your zip code who exit America each year for medical care? Sarah found several in her hometown through a Facebook group. They met for lunch and even established new friendships, bonding over their shared fears, frustrations and experiences. For those who had already been to Mexico for the surgery, they provided real proof that this crazy idea wasn’t so crazy after all.


Once again using the digital world, Sarah and Tony went through an accelerated screening and preparation program and before they knew it, they were on a plane to make the 1600-mile trek to Tijuana.

They weren’t hijacked by drug lords. They didn’t find themselves immersed in Tijuana’s (ahem) nightlife. They were met at the airport by a representative of the surgical center and stayed in a 3-star hotel.

The next day, they toured the facilities and got familiar with the surgeons and their team. What followed sounds much like the surgical experience you would have anywhere in America.

They were pleased with the bedside manner and explanations they received. After a couple of days of monitored recovery, they were back home. Both Sarah and Tony told their primary care physician about their plans before they left and they were soon back in their hands for aftercare.

The results? Several weeks later they are losing weight and enjoying the same outcomes as some of the most successful stateside bariatric stories I have heard.


I have no doubt that a clinician would raise several red flags to this approach, including the importance of a detailed pre-surgery program. You can find plenty of horror stories about surgery in Mexico. Sarah and Tony heard all of that too.

Rob was certainly worried about the horror stories. But his retort cut my own loyalties to the bone.

“Of course we heard about them. But how many horror stories do you hear about hospitals here at home?”

But they didn’t have any horror stories to tell. Instead, they’re now the ones at the lunches and on the forums encouraging others to find another way.


The rise of this new phase of medical tourism comes from a variety of factors. We’ve talked about costs and red tape but it’s also cheaper partly because of cheaper air travel and a growing alliance of industries that are targeting the medical tourist here in the United States. Luxury resorts and hotels are teaming up with foreign providers to make the experience truly an experience.

In the next screen shot from Forbes, we see how resorts are making news by targeting medical tourists.

While the factors above create the need and the means, it’s ultimately the digital world that provides the most crucial factor: validation.

Sarah and Tony didn’t just find research and reviews online. They connected with real people who made their quest seem achievable. They joined a tribe with a unifying point-of-view.

As this trend grows more powerful and the evidence mounts, those 29 patients in your zip code could easily become 109. What will happen when they start looking for care beyond just bariatric or orthopedic surgery?


Sarah is a patient that American health systems shouldn’t lose. But they are. She’s the health care decision maker in the household. She’s tech savvy. She’s a choosy consumer. She should be your next patient.

Sarah’s story doesn’t have to be so gloomy. I see it as a rallying cry for American health care.

I’ve been in enough health system boardrooms to believe that what I am hearing between the lines (and sometimes literally) is “Patients will come to us because we are here and this is the way we deliver care. That’s the way it has always been and this is their option.”

I guess they never met Sarah. Or Tony. Or Rob. Or the hundreds of people in the next several years that will ask them, “Hey, you look great. How did you lose all that weight?”

The patient that too many health systems visualize doesn’t really exist anymore. Their trust in “the way it has always been” has degraded to the point they are willing to get surgery from a physician they’ve never met in a dangerous city. We can’t stop medical tourism but we should learn from the patients that are drawn to it.

We need to listen to these patients. We need to truly understand them.

We need to make our services as easy to use as possible. We need to create digital forums and an online voice that makes the case for why our health systems are relevant to their lives. We need to find ways to connect our patients with each other. We need to build tribes.

We need to restore trust in this American institution, our hospitals, at every opportunity we can. Trust starts with promises and these promises are made through emotional brands. If Sarah had an emotional connection, a true trust in one of the sytems in her backyard, she would not so easily dismiss her care as a commodity that even a stranger could do at a discount price.

Even if your regional competitor achieves this connection and ease of use, do you think Sarah would be willing to drive past your system and travel a few extra miles to get care there if she already went to Mexico? Close to home no longer matters to the new patient.

I don’t have the answers for keeping Sarah home next time but what I do know, is that until we truly understand her, we’ll never win her heart. Otherwise, she’ll keep getting lost to a hospital, far, far away.