With the rising sun comes the morning chores, for 60-year-old Dodie Gilmore of Caddo, Okla. She heads out to feed the cows in the fields and the catfish in the pond on her 180-acre ranch.
She then heads off to work as a real estate agent in nearby Durant. Showing property in these parts of Oklahoma isn't as easy as pulling into the driveway of a McMansion and showing someone around. It involves hopping out of the car repeatedly to open and close lots of gates on big tracts of land, something that has become increasingly difficult for Gilmore because of the arthritis in her hip.
"It's bone grating on bone ... you're never out of pain," says Gilmore.
For more on Americans going overseas to get medical procedures, watch "Nightline" tonight.
Her insurance called this a pre-existing condition and surgery to replace the hip wasn't covered, so Gilmore went online and learned about a procedure called hip resurfacing. She was given estimates of $28,000 to $40,000 for the surgery in the United States -- well beyond the wallet of her or her employer.
But she found that the surgery is performed in India at a fraction of the cost.
A trip to India, she learned, organized by an intermediary called PlanetHospital, would bring her surgical costs down to $7,000. She could even take her sister Carol from Oregon along, stay in a hotel for a few days after, and the total bill wouldn't climb past $10,500 (shopping not included). It was an idea her boss, Martin Van Meter, supported.
So earlier this month, Gilmore decided to go to India, joining a growing number of Americans who in recent years have gone overseas to get medical procedures that they can't afford at home.
On Oct.5, Gilmore and her sister flew to India, spending 30 hours in planes -- no small feat for someone who has trouble sitting or standing in one place for too long.
Arriving in India late at night, she was whisked off to Max Hospital in New Delhi, which resembles a fancy hotel, with glass doors, large sky-lit lobbies, and marble floors that seem to be constantly getting mopped and waxed.
A cadre of staff was waiting and over the next 24 hours while waiting for the surgery, more than 20 personnel would rotate through her room. There were junior and senior residents and attendings, nurses and their supervisors, internists, orthopedists, a dietitian and psychiatrist.
"They get to spend a lot of time with you, and they're genuinely concerned about your problems. In the states, all I would've gotten -- speaking from experience of having a broken leg -- is they just buzz through your room and it's just ... very quick, very impersonal treatment," Gilmore said.
The operating theater was clean and ultramodern and included a high-tech ventilation system that whisks any germs from the operating team away from the patient. The hospital says the infection rates are well below the ones tolerated by the World Health Organization and even the guidelines of the Centers for Disease Control and Prevention.
Gilmore's surgery at Max Hospital took place the morning of Tuesday, Oct.10. The whole procedure took less then a half an hour.
It went very well, Gilmore said. She felt great and was up and walking just two days later. She's still in New Dehli, staying at a hotel near the hospital with her sister. She goes in next week to get her stitches out and said she hopes to head back home before the end of the month.
The titanium parts that were used in Gilmore's procedure are so new, they are still awaiting U.S. Food and Drug Administration approval.
Gilmore's surgeon, Dr. S.K.S. Marya, has already performed more than 150 of these procedures using the new device. He has trained all over the West, including in the United States, England, Switzerland and Australia, and has published in academic journals and recently finished writing a book on hip resurfacings.
The group that helped organize Gilmore's trip, PlanetHospital, has relationships with hospitals in at least seven countries, and all patients have to do is show up, CEO Rudy Rupak said.
"We take care of everything, from their hospital, the airlines, their hotels," Rupak said. "When they arrive in the country of their choice, one of our team members is there to greet them. We take them to their hotel or hospital. We take them to the doctor. We act as their advocate in the country so that if they're not happy with the doctor or the surgeon or the hospital, we'll take them to another place. If there's a dispute with the bill, we stand on the patient's side to fight on behalf of the patient to get satisfaction in their ways."
Van Meter tries to run a profitable small business, but something about these wide-open spaces brings people together a bit more.
"We're kind of a family. Dodie needs this help, and we're willing to help her if this is the only way that she can get the surgery that she needs," said Van Meter, who knows that keeping a fit and productive real estate agent will pay dividends.
"Dodie and she will pay me back many times with her being able to go back into the field, you know, sell a ranch (and she) could get my money back," he said.
It is a choice so many small businesses struggle with -- how to balance the bottom line with the needs of their employees.
Overseas medical travel has been popular for a long time for those patients seeking more minor procedures, like cosmetic surgery, but now everything from hip to heart to brain surgeries are available overseas -- at a fraction of the price.
Rick Wade, spokesman for the American Hospital Association, said the hospitals in his network aren't concerned yet. But he admits that this is a sign of how broken some parts of the American medical system are. And he wonders whether people are willing to take all the risks involved in globetrotting for medical care.
"Does it make a difference to you that there has been a military coup outside the hospital where you just went for surgery?" Wade said.
For some doctors, though, the trend is cause for concern.
"I think the number of people considering going overseas for care should be an absolute red star, if you will, to health policy makers to everyone in elected office, that this system is in serious trouble," said Nancy Dickey, the president of the Health Science Center and vice chancellor for health affairs in the Texas A&M System.
Dickey points out there could be a rise in postoperative care back in the United States if there are complications, and warns that there may not be malpractice laws in place in other countries. But she acknowledges these are some of the reasons health care in the United States is so expensive.
"I may do tests, extensive imaging ... not because I want those test results but because I want those test results to protect me down the road in case you want to sue me," Dickey said.
The cost disparity between health care in the United States and in other countries helps create a market that companies like Planet Hospital thrive in.
"An international price comparison of 15 procedures reveals that there could be savings of around $1.4 billion annually, even if only one in 10 U.S. patients choose to undergo treatment abroad," World Bank economist Aaditya Mattoo wrote in the journal Health Affairs.
However, the World Bank report also found that health insurance providers discriminate based on location of care, meaning many just won't pay for medical care overseas. There is only so far "out of network" you can be.
In the room next to Gilmore's at her New Delhi hospital was another American hip patient, Rick Thues, a 53-year-old computer consultant from California who loves to skydive and wanted legs strong enough to land on.
He said he would have preferred to go to a hospital in Orange County, Calif., where one of the pioneers in the field works, but that his HMO let him down.
"They denied my requests for hip resurfacing, even though it costs no more -- they didn't have a code for it -- and therefore they flat denied my hip resurfacing as opposed to hip replacement," Thues said.
Thues took his claim to the state board of appeals and lost, although one doctor agreed that it was the right surgery. The other two believed there wasn't enough historical evidence: Hip resurfacing has only recently been approved in the United States.
"I don't think I had another choice. I really don't. What could I have done? I -- well, I could've paid more money. I could've waited four to six months. I could've gotten last year's prosthetic. But I didn't. I decided I wanted the state of the art, and I wanted it now because I needed it now," he said.
Max Hospital is one of nearly a half dozen new hospitals popping up within a half hour of the Delhi International Airport. By the year 2010, there will be 2000 more Western-standard hospital beds -- at Indian prices.
Many of the new hospitals are already accredited by an organization called the Joint Commission, which also helps set the standard for thousands of hospitals in the United States, and has approved more than 100 hospitals around the world in the past six years.
One of India's most ambitious new hospitals, in the town of Gurgaon, was spearheaded by Dr. Naresh Trehan, the most prominent heart surgeons in India today. He used to work in the United States but came back to build a hospital that offered the same standard of care for his countrymen back home.
The existing hospital already handles a volume of heart surgeries greater than most Western hospitals, but his latest research specialty institution hopes to combine the best of Eastern and Western medicines for both international and domestic clients.
"International patients are great, but you have to realize there are 300 million middle-class Indians who can afford the kind of care we are providing," Trehan said.
Analysts wonder what impact this will have on health care in the United States. People like Dodie Gilmore are finding less-expensive health care outside the United States, and the quality of care she received in India has reset the bar for what she feels entitled to in a medical experience.
"I really believe that health care is really the only industry in America that's never really had competition before, and competition is healthy," PlanetHospital's Rupak said.