The Patient Traffickers (Los traficantes de pacientes)
Dubious medical tourism agencies are bringing foreign patients to Germany for treatment,
and our hospitals are paying them.
Ruslana Fadiva is dancing, as her grandparents watch. Klavdia Petrova, 65, and her husband
Leonti Fadiv, 62, are in the gym hall of the town of Yoshkar-Ola, 700 km east of Moscow. While
their eight-year-old granddaughter takes her first gymnastics test, her grandparents talk about a
place they have never actually visited: Düsseldorf. "Do you remember how I walked three times
round the Kazan Kremlin in the hope that Ruslana would be healed in Düsseldorf?", she asks
him. Ruslana was suffering from cancer and was treated in 2008 at the University Clinic
Düsseldorf at the age of four.
"Yes, of course", answers her husband, and then the couple tell me about the middleman from
Lüdenscheid in Westphalia who certainly helped their granddaughter survive but whom the
family has been suing for several years now because he charged them much more than necessary
for his services. The amount in dispute is around EUR 45 000. Medical tourism agencies are
arranging for patients from abroad to be brought to German hospitals for treatment, benefiting
from the excellent reputation of the German medical profession. For their fee, the agents, most of
whom have their roots in the patients' home country, find a suitable hospital in Germany,
establish the costs, arrange the dates, translate diagnostic documents into German and provide
interpreters for the patients during their stay.
A noble enterprise, one would think. Yet examples from German hospitals show that it's not all
above board: one doctor tells of an agent who took as much money again from the patient as the
hospital treatment actually cost. The Head of the Office for International Patients at the
University Clinic in Düsseldorf tells us that she has had "wretched experiences" with agencies.
The State-Secretary of the Bavarian State Ministry for Environment and Health tells as that she
knows "just one or two agencies that are reliable". One member of the board of the Regional
Chamber of Medicine refuses to call them "agents", preferring the term "patient trafficker".
President of the German Medical Association Frank Ulrich Montgomery says that he is aware of
"dubious agencies importing" patients into Germany. One nurse at a German university hospital
even tells us that the more ruthless among them will stop at nothing….
Jens Juszczak is in his office, E108, on the first floor of the Bonn-Rhein-Sieg University in Sankt
Augustin, where he is a research assistant in Economics. For ten years now, he has been studying
the phenomenon of medical tourism agencies. He has the latest research on his desk – in 2012,
some 200 000 foreign patients came to Germany for treatment. Apparently they earn German
hospitals sorely needed revenue of around a billion euros a year, which is why the benefits of
health tourism are often trumpeted and why hospitals compete to attract the likes of sheikhs and
oligarchs. The fact that less well-off patients, such as Ruslana Fadiva, are also brought to
Germany is less often told. And hardly anyone talks about the agents who position themselves as
middlemen between hospitals and patients. Juszczak tells me that around two thirds of all
hospitals treating foreign patients use the services of medical tourism agents who, like estate
agents, earn a commission for each patient found. It is a murky market. Juszczak tells us that up
to one thousand medical tourism agencies are working with German hospitals, needing for their
business nothing more than a mobile telephone, contacts abroad and knowledge of the language
of the country in question. Anyone can set themselves up as a medical tourism agent. In most
cases, none of the medical staff have any idea what the agents agree with their clients. Marlies
von Borries, Head of the Office for International Patients at the University Clinic in Düsseldorf,
confirms this: "No, we have no idea."
The day after his daughter's competition, we find Ruslana's father Roman Fadiv at his kitchen
table on the fourth floor of a five-storey block in Yoshkar-Ola, where he lives with his wife,
Nadeshda, and their two children, Ruslana and Serafin, in a light-filled three-room apartment. In
front of him is an invoice for more than EUR 100 000 from a medical tourism agency in
Lüdenscheid. He has sent his daughter to play in her bedroom, to spare her hearing the details of
her illness. In February 2008, Ruslana was suffering constant tummy ache. The paediatric clinic
in Yoshkar-Ola diagnosed an abdominal cyst – the first misdiagnosis, as the Fadivs now know.
Ruslana's father insists on taking the reporters to the hospital at Volkova 104. It is a grey and red
building built in the heyday of the Soviet era. Stained mattresses are piled up, out-of-date
medicines age within easy reach in dented boxes, and in one corner is a potted plant bearing the
label: "This plant is sick – please do not touch". Roman Fadiv stops to look at the plant: "Life in
Russia is good, as long as you stay healthy and don't get ill."
"Transfer the money today and you can be in Germany by tomorrow"
Not until four months had passed since the first examination in Yoshkar-Ola and after several
more misdiagnoses at various Moscow hospitals ("oncological illness ruled out") did the Fadivs
learn what was really wrong with their daughter: Burkitt's lymphoma, a cancer of the lymphatic
gland from which the prospects of recovery are good as long as it is treated quickly. As it had
already taken the Russian doctors four months to make the diagnosis, the family had little
confidence in the Russian health system. They consulted the internet in search of a hospital in
Germany. According to Juszczak, this is the usual way of proceeding, with most Russians using
the Russian "Yandex" search engine. The search string "treatment in Germany" brings up almost
exclusively links to agencies but no hospitals. The Fadivs plumped for the agency in Lüdenscheid
because its website looked serious, with photos of the owner together with trustworthy-looking
men in white coats. At the end of July 2008, they called the agent: "Transfer the money today and
you can be in Germany by tomorrow", said an employee on the telephone. "I can find it",
answered Mr Fadiv. The Fadivs are, by western European standards, a normal, middle-class
family, neither oligarchs nor destitute: four people living in a three-room apartment, with bunk
beds for the children, a washing machine. Mr Fadiv owns four clothes shops in the town. The
bank gave them a loan of EUR 80 000, and they borrowed more money from friends. To pay
back these debts and the first loan, they had to take out another loan, which they have still not
When they arrived in Düsseldorf, the Fadivs felt "helpless and speechless". Their interpreter,
contracted through the agency, had little understanding of medical terminology. On several
occasions while they were talking to the specialist at the hospital in Germany, she told them "I
can't translate that – I don't understand it myself." Roman Fadiv wanted to complain to the
agency, but whenever he called, the answer was that the down-payment of EUR 100 000 was not
enough and that he should transfer more. He started to have doubts, and asked whether he could
see the hospital's bills. When his request was refused, he turned to the hospital's International
Office, where he learned that the hospital's bill was for around EUR 40 000, far less than he
originally paid as a deposit. Worse still, the Fadivs had originally understood that the
EUR 100 000 was a deposit and that, if there was any money left, they would receive it back in
their account, minus the commission. This interpretation was confirmed by Hagen District Court
in a part judgement in 2010: the payment "was not a flat-rate (...), but rather a deposit."
When Die ZEIT enquired, the agency's lawyer replied that the agency had also paid the family's
accommodation costs, which is why the amount was so high. The Fadivs dispute that, saying that
they had stayed with acquaintances in Düsseldorf and showing photographs of student digs near
the hospital which they claim to have paid for themselves. The lawyer does not provide us with
any evidence of additional costs, beyond the invoices from the hospital and the interpreter
amounting to around EUR 45 000. The lawyer writes that his recommendation is to "await the
Every German hospital receives a fixed amount for a particular treatment, be it EUR 1 500 for a
birth without complications or around EUR 100 000 for a liver transplant. These flat rates, which
have existed for ten years, are intended to shorten stays in hospital and keep costs down. Before,
hospitals could boost profits by keeping patients in for as long as possible and then billing them
per in-patient day. With the new flat-rate system, however, hospital staff have to ensure that no
patients exceed their 'upper in-patient time limit' – or the health insurance fund will reduce the
payment. The consequence of this has been empty hospital beds, causing hospitals in rural areas
in particular to close.
The hospitals were looking for additional sources of income and hit on the idea of attracting
patients from abroad, approaching them at medical trade fairs in Dubai or Moscow. These
patients pay for themselves, and their money flows directly to the hospitals, where it can be spent
on new medical equipment, which also benefits German patients in the health insurance funds. It
is legal to negotiate the price freely with people paying for themselves. But if the prices are
extortionate then things can get tricky – for example if the invoiced price for the service is more
than twice the cost price. Lawyers assume that a case of profiteering exists if a weaker party is
being exploited, which was certainly the case with Ruslana Fadiva, whose parents were fearing
for her life.
Hospitals paying bonuses for 'head hunted' patients
The Office for International Patients of the University Clinic Düsseldorf is prepared for clients
from abroad. A large blue sign in Cyrillic and Arabic script hangs on the wall on the way to the
office. According to the Head of department Marlies von Borries, their hospital also works with
agencies but has become more careful – and no longer does business with the agency in
Lüdenscheid. Furthermore, for the past year and a half, it has always sent out two invoices: one to
the agency and one to the patient. Von Borries underlines repeatedly that her hospital is
"different": "We don't pay commissions!"
Experts like Juszscak, however, say that many hospitals pay the commissions 'customary in the
sector'. In other words, agencies earn a commission from hospitals when they bring in foreign
patients. Some mention a 'head hunting fee' which is around 15 percent of the treatment cost. So
the agencies are raking it in – from both patients and hospitals.
Kiel Regional Court ruled as early as the end of 2011 that commission agreements between
hospitals and agencies were unethical. An agent had sued a teaching hospital in northern
Germany for not paying the agreed 22.5 percent commission per patient. "The court declared the
contract null and void, because it was liable to damage the relationship of trust between doctor
and patient through excessive commercialisation", according to Berlin health lawyer Norman
Langhoff. Die ZEIT has seen letters from several German hospitals agreeing commissions of this
kind. According to President of the German Medical Association Frank Ulrich Montgomery these
are "clear cases of illegal assignment of patients for money, prohibited under the rules governing
the medical profession".
Julia Laube* cannot keep quiet any longer. She is a young assistant doctor at a teaching hospital
in southern Germany and knows how important foreign patients are to her employer. Yet, when
she describes how the Russian woman sent to her hospital by an agency died, she uses the same
word again and again – 'Mutterseelenallein', meaning 'alone in the world' – and looks over her
shoulder, as if to convince herself that no one is listening. If her boss finds out she has been
talking about the hospital's business, she could lose her job. 'Mutterseelenallein.'
Yet she wants to talk about it. She no longer wants to be complicit in a system where patients
from abroad are used as pawns in a game played between the agents and hospitals, where cost is
the only consideration. "I was devastated to see how my patient travelled thousands of kilometres
from her family to die here", she says. The patient had pancreatic cancer. "At least a month
before she died, we realised that she was never going to pull through." But her family had no
money to visit her. She wondered what the agency had promised to persuade her to come to
Germany. She asked the clinical director whether there were "any rules concerning medical
tourism agencies and their patients". "No", was the brief answer.
This is a business with no regulation and no quality control. Green Party Prevention and Patient
Rights spokeswoman Maria Klein-Schmeink would like to change this and is calling for a
certification body for these agencies, as it is just too easy to "exploit" patients from abroad, she
says. Melanie Huml (CSU), State Secretary at the Bavarian Health Ministry, says that there is a
fundamental mismatch between the murky world of the agencies and the glossy blue and white
brochures in the Bavarian colours promoting Bavarian medicine around the world and attracting
people like the Fadivs to Germany. For this reason, Ms Huml, herself a doctor, is planning to set
up an office to provide foreign patients with trustworthy information about treatment in Germany
– without any go-between. The office is set to open this year, and the regional Government has
earmarked five million euros for the project.
Roman Fadiv thinks that this initiative, endorsed by none other than Bavaria's Minister-President
Horst Seehofer (CSU) in a Russian-language brochure, is a good way to attract patients to
Germany. If it had existed when Ruslana's illness was diagnosed, perhaps he would not have to
travel to Hagen in mid-April for the next court hearing. When asked whether he acted rashly and
naively in 2008, he replies that he was ready to seize any opportunity to save his daughter's life.
"Wouldn't you do the same?" he asks.
*Not her real name
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