Jeremy Carr: All right, hello, health heads. Welcome, and thank you for checking into this dose of the Healthcare Uprising. I'm your producer, Jeremy Carr, here on the couch with your host, Heather Pierce. So what is on our agenda for today, Heather?

Heather Pierce: Today we have Dr. Kelli Frias from American University. She is an associate professor of marketing, but don't let that fool you. She did some incredibly wonderful research around healthcare: crossing the border into Mexico to get healthcare, cost transparency. We talk about patient-driven healthcare choices because of the access you get when you walk into Mexico or drive into Mexico, and where insurance lies with all of this.

Jeremy Carr: Yep, and it's very much tied to people who have employer-provided healthcare, which is an important part of this conversation as well. And also the psychology of crossing a border to get healthcare. That's probably the coolest, or at least in my mind the most fascinating, part of this conversation.

Heather Pierce: I agree. Yep.

Jeremy Carr: Stuff I never would have thought about that is now going to tickle my brain for days. So it's a very interesting conversation that goes into a lot of different things. Without further ado, let's get into our conversation with Kelli Frias from American University.

Heather Pierce: Hi, and welcome to the Healthcare Uprising podcast. Today we have with us Kelli Frias, associate professor of marketing at American University. Welcome to the show. We're so happy to have you.

Kelli Frias: Thank you for having me. I'm very excited for today.

Heather Pierce: Yeah, me too. So let me tell you what's going on here. We are going to talk about medical tourism. We're going to talk about price transparency. We're going to talk about more consumer-driven healthcare. But I would say the medical tourism piece is probably going to drive the majority of this conversation. You've done an immense amount of research in this space. Before we get into the details, give us a little background on your teaching history, your professional history, and anything personal that led you to this research and why you care about it so much.

Kelli Frias: Yeah, I'm happy to share. I've been at American University here in Washington, D.C., for the last eight years. Before that I was at Texas Tech University in West Texas. Before that I grew up in Southern California and did my PhD at Arizona. I had a family that crossed the border. They had what we would consider great insurance in the U.S. and still found it necessary to cross the border regularly for healthcare. That's always resonated with me. And as a marketing professor, since we study consumer journeys and a lot of what consumers do to make decisions, I get to keep studying this. So it's a lot of fun, and I'm happy to share today.

Heather Pierce: I'm excited. I'm also a fellow marketing nerd, so I love talking about consumer behavior and why people do things. I always say that I studied anthropology in college. I got a minor in it, and I'm still convinced that has helped me in my marketing career, because human behavior is so indicative of the choices we make when we buy something. We don't really change much, do we?

Kelli Frias: No, we don't.

Heather Pierce: We don't. So I appreciate your work so much. With that, let's talk about the research you've done. Your research is focused on insured Americans, through employer-provided healthcare, correct?

Kelli Frias: Yes.

Heather Pierce: Okay. And it looks at how medical tourism, crossing the border for care, has played into their overall healthcare journeys. Let's set things up. Maybe start with the research, if that makes sense, and where it's led you.

Kelli Frias: Yeah. We've spent probably the last six years trying to understand what this looks like for consumers who would consider themselves to have a good job. I think we've all heard that you get a good job, you get good benefits, and you can support yourself and your family. You've made it. What we found over the past six years is a whole host of people who are insured through their employers and just can't afford standard care. They're primarily people living closer to the border, obviously. This is different from the way we've talked about medical tourism in the past, where you go once for a procedure, maybe even a cosmetic procedure. These folks are going on a regular basis. It's just part of their monthly or quarterly practice of being able to afford and access healthcare.

Jeremy Carr: Yeah. It comes up way too much on this podcast that people have insurance they've been paying for forever, and it's supposedly good insurance, and then something goes wrong and nothing's covered.

Heather Pierce: Right. Yeah, we get this. They can't afford it.

Jeremy Carr: They've already paid all this insurance, and then they show up to the doctor and can't afford to pay for what they need because they're still getting charged for it. It's maddening.

Kelli Frias: And the costs are going up exponentially. In our study we looked at folks who I would say have great jobs: police officers, teachers, educated folks who are working full-time. One of the most difficult kinds of medical treatment is when someone has pain. My shoulder's in pain, I need to go see a doctor. What starts as an initial visit might become a multi-stage, multi-month process. You go in, the doctor says go get an X-ray. You come back, and they say go to physical therapy. You come back again. Those lengthy treatments are just so expensive for many consumers. And then we can talk about the whole accessibility issue on the other side: how difficult it is just to get access to care.

Heather Pierce: Yeah, which is a growing problem here in the United States. And your research focused solely on receiving care in Mexico, correct? This did not include Canada?

Kelli Frias: No.

Heather Pierce: Okay, just to be clear for anyone listening. Like we were saying before we started recording, we live here in Arizona, and going across the border for healthcare is a pretty common thing, particularly dental.

Kelli Frias: Yes.

Heather Pierce: Was dental included in your research, or was it just medical?

Kelli Frias: I'm actually working on a more recent study from the last year. We're looking at dental, particularly in Molar City, or Los Algodones, if you've heard that term.

Heather Pierce: Yes.

Kelli Frias: You know the term.

Heather Pierce: I do.

Kelli Frias: We're also looking at medical creators, the content creators who talk about this online. So how the navigation process happens, but on TikTok.

Heather Pierce: Yeah. The closer you get to the border... I drove to San Diego over the summer, and I'm going again in a few weeks, and you see the billboards. It's one after another, and they all say... say the name of the town again? I don't want to mess it up.

Kelli Frias: Los Algodones.

Heather Pierce: Los Algodones. It's every single one.

Kelli Frias: You can just call it Molar City.

Heather Pierce: Or Molar City. We all do. It's crazy. They're just there, one after another, the whole way, because you get really close to the border there. It's one little turn-off, and boop, there you are.

Jeremy Carr: Don't take that turn by mistake. That changes your whole day.

Heather Pierce: That is true.

Jeremy Carr: You'll end up with some sort of dental service whether you want it or not, and you'll come back with some kind of new tooth in your head.

Heather Pierce: Something's going to happen. Okay, cool. Once you finish that research, we're going to have to have you come back and talk about it. But for now, let's focus on the medical side. Within the research, what surprised you the most? There are some obvious things, like access and cost. Is there anything else that stood out to you?

Kelli Frias: Yeah. Two things stood out for us, and we've been talking about this for the last couple of years. We hear a lot of rhetoric around price transparency, the idea that giving consumers more information, or more access to information, will actually help. What we found is that when you give consumers more information but they're in a different market, or they're being exposed to a consumer journey they've never experienced, it can be overwhelming and backfire. We call those backfires "cue misfires." Essentially, you think you've made a good decision and you've convinced yourself of it. You've done the research on the provider or the cost. But you really aren't making great decisions. In many ways you might take what we'd think of as an intellectual shortcut just to get access to care.

Heather Pierce: Oh, okay. That's interesting. I would never have considered that.

Jeremy Carr: So you're actually getting a worse outcome because you're trying to get there quicker, pay less, or whatever?

Kelli Frias: Yeah, basically. You feel like you've done a lot of work, so the decision feels like one you worked hard to reach. Now that you're there, you feel a sense of agency: I've made the decision, so it must be a good decision. You feel confident in it even when it's not a good decision.

I'll give you an example. We saw lots of folks trying to make comparisons between their U.S. provider and their Mexican provider. In the U.S., if you're at a physician's office and you're made to wait in the waiting room, you think that physician probably doesn't care about your time. Maybe they're behind schedule. You don't think very highly of them. However, take that same cue in Mexico. I walk into a clinic and see lots of people in the waiting room, and I think, wow, this is probably a good doctor, because locals are willing to wait for this doctor.

So we asked people: you're using this one cue, the waiting room, as an assessment of quality. Have you ever really thought through that process? We did a lot of shopping with them. We followed them into Mexico and shopped alongside them. It was just a shortcut. As you said, in Molar City there's clinic after clinic. They pop their head in, look quickly, and say, wow, this waiting room is full, I should probably stay here and wait. There were no other assessments of quality. That's not to suggest the provider was good or bad. It's just that that's where the assessment stops.

Heather Pierce: That is so crazy, because I'm thinking about how many times I've been in an overcrowded waiting room, waiting and thinking, this is so annoying, I need to find another doctor because I'm tired of waiting every single time I'm here.

Jeremy Carr: Yes. It is interesting. It's like they assume all the doctors in America are equal, but as soon as they cross the border, the dynamics change for some reason.

Heather Pierce: That's interesting. I don't know if this was part of your research, but did you find any differences in quality between these providers who were apparently all amazing and worth waiting for?

Kelli Frias: We didn't do any diagnostic follow-up, so we can't assess whether people actually received better treatment. What we did see is that a lot of folks talked about being with the provider for a longer amount of time, so they felt listened to. They felt like the provider wasn't under the gun of an insurance company suggesting they spend four minutes with each patient. They really felt cared for.

What's also interesting, and I think this goes back to the ability to get immediate access to care: I'll never forget, we were in a pharmacy with a patient. They went up to the pharmacist, or the person who looked like the pharmacist, and said, "I'm having these symptoms, do you have something for my pain?" They took the medication immediately, and within less than 30 seconds they turned to me and said, "I feel better. I feel so much better." Now, that's not how it works. It could have worked, yes. But there's something about that immediate access that gives people a sense of relief in a way you just can't get in the U.S.

Heather Pierce: Right. It's such a different psychology. That's wild.

Kelli Frias: It is.

Heather Pierce: And of course, now you know where my head's going. I don't know how many answers you have to this question, but what about the quality of healthcare in Mexico in general? I think a lot of people think, well, it's a third-world country, it's not the United States, everything in the United States is better. Is it, though? What's the assessment there, if you have one, or even an educated opinion?

Kelli Frias: I can say that we had lots of informants we followed for well over a year who talked about getting care there for many years, sometimes for generations. Sometimes folks had a neurologist on both sides of the border, and the two would confer so each provider knew about the other. We heard from providers who said that yes, you're going to get just as good care for many conditions, often for folks going for acute needs: I have a sore throat, I need a particular medication, and I know what that medication is. They were getting great access.

I'd also point to some of the providers here. Some hospital systems in Texas are building facilities on the Mexican side of the border. Binational accreditation is happening. There are also discussions of binational healthcare plans. Those are happening in California, and now we're looking at what that would look like in Texas. For a time that was outlawed. So I think the infrastructure is in place for this to happen, and if costs continue to grow at the rate we're seeing now, I can't imagine it won't become a bigger need in the future.

Heather Pierce: And just to clarify, I know a couple of examples from working in healthcare for as long as I have in Arizona, Texas, and California...

Jeremy Carr: She's been everywhere.

Heather Pierce: Might as well throw New Mexico in there, although I've spent the least amount of time working in that market. I know of people who live on the border and go into Mexico for care through employer-provided health plans. Bashas', a grocery store chain here in Arizona... I know this because one of my best friends ran benefits for them. They actually provided coverage for their employees at certain facilities across the border. But that was employer-specific. What you're talking about is health plans that are multinational, correct? Not specific to an employer?

Kelli Frias: Both are happening. For example, Aetna has a plan, but it's offered through a particular employer. In El Paso, the school district has that option, or has had it in the past. So it's still facilitated through your employer. But the Bashas' example is a great example of a company seeing its employees' needs and trying to meet them where they are. If we're talking about employees not getting care versus having some level of care, or continuous care, this is a huge opportunity to maintain your health.

Heather Pierce: And were the majority of the people you followed in the research primarily going across the border for regular acute care, like what you'd get at an urgent care or a primary care provider's office? Or were you also looking at people with chronic conditions or comorbidities who need multiple specialists, things of that nature?

Kelli Frias: We saw a varied list. Someone might have rheumatoid arthritis and also go for strep throat, so they could be seeing a rheumatologist and going regularly for other conditions too. What we did notice is that the majority of the folks going were women. That raises some interesting concerns. We're talking about a border in northern Mexico where violence is obviously a concern on both sides, and particularly for women. So we have women attempting to care for their families, taking on the brunt of that role for the entire family, who are also the ones crossing back and forth.

Heather Pierce: Oh, wow. I hadn't really considered that. That's a good point. And women are primarily the healthcare decision-makers. They're the nurturers, they take care of the kids. Sorry, honey, but my husband has taken my kids to the doctor a very short number of times over the course of their lives. So, surprise.

Kelli Frias: Yeah, we saw this. Women would make plans to go together, so you might have a younger family member decide to go with an older female family member. The way they would navigate potential violence was to check online groups the day of the trip: WhatsApp, Facebook, mom groups. Is it safe to travel today? Particularly in places like Juárez, which we visited several times. That's part of the navigation process. Is the border open today? What's the wait like? Can we get through? Should we walk? Should we drive? All of those factors come into play. So you can start to see why walking in and finding a facility with a crowded waiting room might become the deciding factor when you've already worked through all these other factors just to cross.

None of the folks we talked with said that if they had all the money and all the benefits in the world they would travel into Mexico. The reason is that they felt that, as members of a community in the U.S., they should be able to access care in the U.S. This is your home.

Heather Pierce: Yes. Yeah.

Jeremy Carr: So you're in D.C. I don't know if this is part of your research, but I'm going to ask anyway. Has there been a shift in the amount of medical tourism across the border since the new administration took over and started all the chaos with the border and immigration? Have you tracked any statistics on that?

Kelli Frias: We haven't tracked the statistics, but I do scrape TikTok for videos about crossing. Interestingly, as you might expect, there's a lot less tracking of who's leaving the country than who's coming in, so access to those numbers has gotten harder in just the past couple of years. We estimate about a million people travel into Mexico each year for care, but that number is really difficult to pin down because we don't record the healthcare piece specifically. We've also seen complaints in multiple forums about U.S. citizens or residents trying to cross, and because wait times are extended, they've had to navigate around that to get some of their care. So there's an expectation that you'll have access to this other market, and you may not.

Jeremy Carr: Yeah, I know there was a while there when Mexico actually shut down the crossing at Yuma, where everybody goes to get to Molar City and places like that. They literally weren't letting people through for a little while, and then they were putting limits on how many people could cross per day. I haven't heard anything about it in months, so I don't even know where that stands now. But I know they were purposely keeping people from going there for a while.

Heather Pierce: Yeah, there's Lukeville, on the road to Rocky Point, or Puerto Peñasco, which is Arizona's beach, as we call it. We've been going down there for years. I've been in a couple of Facebook groups, and I remember hearing about them shutting that border down and being more restrictive in general. Even something about not being able to bring dogs into the country anymore, for people who live down there. That has nothing to do with healthcare per se, but the back-and-forth seems more restricted, and I'd say there's more fear in general. A lot of people, Americans, are very concerned about going down there.

Jeremy Carr: About not being let back in, even as Americans.

Heather Pierce: That's right. That's how things are right now.

Jeremy Carr: That's messed up.

Kelli Frias: Yeah, any kind of delay. You know how hard it is. When you have a doctor's visit, you take the day off, or half the day, and the same thing is happening here. If you can't get back, you're in a world of hurt. If it's a four-hour wait to get back across the border and you've left your kids with a babysitter, or you have to pick them up at a certain time... There's ambiguity about how quickly you can go and come back, and that just adds to the stress and tension for someone who's already in a need state for healthcare.

Heather Pierce: Yeah. One of the other things your clinical research included... sorry, not your clinical research, your research. We have so many doctors on the show that "clinical" is part of my regular vocabulary. It just rolls off the tongue. Part of your research looked at people taking healthcare decisions into their own hands, through technology. We joke all the time on this show about how many people use Dr. Google to assess themselves.

Jeremy Carr: I'm still on WebMD. That's how far behind I am.

Heather Pierce: You're like a caveman. My husband probably still uses WebMD.

Jeremy Carr: Hence the beard.

Heather Pierce: Yeah. But now we've got ChatGPT and Claude and all this AI stuff, and every Google search is essentially AI output. Your research was probably done before ChatGPT and Claude became crazy popular, which I'd say has been just in the last 12 to 18 months. But what have you found about people making their own medical decisions, or at least trying to, or driving their care more than a physician does? And why?

Kelli Frias: One of my biggest concerns is the healthcare record. I think there's a real opportunity for people with AI and that kind of access. Almost everyone uses their phone to keep some sort of notes or records, so there's potential benefit in being able to keep your own healthcare record. I think that would be an amazing experience for patients, not having to request records from various providers.

I also think it alleviates a lot of the shame. We saw people who were afraid to tell their rheumatologist, for example, that they had crossed, because they'd had to get a dental appointment for their child, and the rheumatologist had explicitly said, "I don't want you crossing into Mexico, it's a third-world country." So they wouldn't share that information, or they wouldn't share that they'd taken a particular prescription. When you give people access to their entire record, that's very important.

Where we are now, I think, is a state of having lots of information, maybe too much, with AI. AI is a production machine, and we really haven't taught consumers how to work through all that information. How do we audit it for good information versus bad information?

And if we want to think about the really dark side of this, there's prompt injection. There's a lot of discussion about whether particular companies, and insurance companies are one that's come up in the news, are injecting these AI chatbots with information that would restrict consumers, or make them think they're restricted, from seeing an ER or a physician. Essentially, if I put in your prompt and it returns something like, "This isn't really that serious, you should wait, hold off a couple more days, this isn't serious enough to go to the ER," when it might in fact be serious enough to go to the ER. Is this a way companies are using AI as a cost-cutting measure?

Heather Pierce: Oh my God. I had never even thought of that until you said it, and it makes so much sense. It's totally possible to do.

Kelli Frias: Yes. It's probable, let's put it that way.

Jeremy Carr: Frightening as well.

Heather Pierce: It is. The other thing I was worried about before you said that was the whole thing where you search Google about something that's wrong with you, and it's, "Oh my God, I'm dying." Like you're absolutely dying. But then there's the other extreme.

Kelli Frias: Yes.

Heather Pierce: Which is just as terrible: maybe I'm not taking it seriously enough. That's essentially what you were just saying.

Jeremy Carr: It's like AI telling you to just walk it off. You're fine, just walk it off.

Heather Pierce: Right. That's a scary thought.

Jeremy Carr: Don't even worry about it, you're fine.

Heather Pierce: Yes. Whoa. Okay, that's kind of mind-blowing to think about.

Kelli Frias: And going back to our work, when you add on top of that women in particular, who, let's call them the CFOs of the family, often delay care anyway. Parents delay their own care for their children: I'll take my child in, but I'll wait until it gets really bad for me. We saw that women did that more than any other group, particularly those with small children. Then add to that, "I use ChatGPT or another LLM for my medical advice," and I may delay even further. It's a huge concern, and it should be a huge concern for all of us, nationally and internationally, in terms of how we're going to improve care.

Heather Pierce: Yeah. A question for you, too. I know this about employer-sponsored health plans: you have a network, and the providers are in that network. That's true of any plan, whether it's Medicaid, Medicare, or an ACA plan. But for the people going across the border for medical care, when they go to those doctors or facilities or urgent cares, are they just paying cash out of pocket? Or do they get negotiated cash rates?

Kelli Frias: Most often the cash rates are given in advance, or they're posted, so it's very easy to see. Say I want to go in and speak to the doctor about a cold I'm having. That cost is on a poster on the wall. On average it's two to three dollars U.S., so you can see it up front. Or many offices will message you on WhatsApp and tell you the cost in advance. If you think about an X-ray or an MRI here, we may not know for months what that costs us out of pocket. There, you'll know immediately.

Heather Pierce: Ah, okay. And we'll talk a little more about cost transparency, I'm sure, but that's a big problem here. We just had Kelsey Denimon on, the co-founder of a new app and website platform called Altered Health. It's all about showing the differences between negotiated rates with insurance companies and the cash-pay option. You can put in, say, a colonoscopy, plus your zip code, choose your insurance company, and see what it would cost by facility, all over Arizona. I tested it, and it showed what it would cost me to pay cash at one facility versus another, and also what it would cost through insurance.

So going back to what you said at the beginning, sometimes too much information around cost transparency is almost confusing.

Kelli Frias: Yes.

Heather Pierce: I could see how you might get stuck. But we also want cost transparency in the United States. It also shows how crazy things are. How can there be such a massive variance in cost depending on who you are, where you live, and what facility or doctor you go to, for the exact same thing?

Kelli Frias: Right, yes. When we think about things like an MRI, those kinds of shoppable procedures, there's an assumption that they're all the same, that you're getting the same scan. And you probably are. But historically, we as consumers haven't done any price shopping, and it's a strange market. I always use the example of a birthday cake, because I feel like we all immediately have it in our heads. What's the average price of a birthday cake? What's a really expensive birthday cake, and what would you expect it to taste like? What would the ingredients be? What would it cost at the local grocery store? We could all answer those questions immediately.

But if I asked you about an MRI and said this one is $2,000 out of pocket versus $2,500, you wouldn't know whether both are high or both are low, or whether one is better quality. So we use these heuristics. We say, well, it's my body, I want the $2,500 one. But that may have no association with quality at all. It's really tough, because this is an emotionally laden position to be in as a consumer, and now you're being asked to go out and do some of the shopping.

That's one of the reasons I think looking at cross-border shopping is so important. These folks are really astute, strategic shoppers. They know prices inside and out. They'll tell you the cost of a prescription in the U.S. versus in Mexico to the penny. We just don't have any other group of people in the U.S. with that kind of shopping skill set.

Heather Pierce: How do you become one of these people? Is it just that so many people in your orbit are doing it that you become more knowledgeable much more quickly?

Kelli Frias: I think so. We had people come up to us and say they're "border people." We've been doing this for years. I know with my own family, there was no border, in a sense. You had family living on both sides, and if the border crosses you, that doesn't really shift your cultural awareness, until someone says you absolutely can't shop here for healthcare. Then all of a sudden people start figuring out ways to navigate around that, because they've been doing it successfully for generations. So I do think there's a big cultural element to it. Whether or not you're of Mexican American or Mexican descent, just being in proximity, connecting with someone there, there's a big sense of community as well.

Heather Pierce: That's really interesting. Fun side note: I just learned recently that my husband's grandmother, who was raised in Bisbee... I'm sure you're familiar with it, since you were down in Tucson. She's no longer alive; she was born in the 1930s. I found out she was actually born in Mexico, because there wasn't a hospital nearby and Tucson was too far. Her parents drove over the border to Mexico, so she was technically born in Mexico, and then they just drove home to Bisbee.

Kelli Frias: That is a very Bisbee story, isn't it?

Heather Pierce: Isn't that crazy?

Kelli Frias: Yeah. My grandmother was born in El Paso, and some of her siblings were born in Mexico, and there was nothing unusual about that. It's 500 feet away. And it's still that way. You're at the Marriott in downtown El Paso, you walk 200 feet, and you're in Mexico. If you haven't lived there or visited, it may seem like there are two extremes, but there really aren't.

Jeremy Carr: Yeah, borders are just lines on a piece of paper. When you go there in real life, you can't even tell it's there.

Heather Pierce: I'd say it's not really a thing. Going down to Rocky Point, aside from the actual checkpoint, where it's very clear you're at the border... I've walked across the bridge in Tijuana... no, not Tijuana, Nogales, sorry. I literally got dropped off and picked up, because I was crazy in college and decided taking a charter bus down to Mazatlán at age 20 was a really good idea. Hey, we survived. But I'll never forget walking across in Nogales. It felt kind of the same on both sides.

Jeremy Carr: You're still in the same spot. You didn't go anywhere.

Heather Pierce: Yeah.

Kelli Frias: You are. There's a Walgreens on one side and a Walgreens on the other, and a Walmart on one side and a Walmart on the other.

Jeremy Carr: Exactly. Niagara Falls is my reference, since I grew up in New England. You're on the Buffalo side, then you cross over and you're in Canada, and it's the exact same spot. You're still at Niagara Falls. Nothing changes when you cross the border.

Heather Pierce: Right, they're imaginary lines. You might have to exchange your currency.

Jeremy Carr: Exactly. Now we're on pesos.

Heather Pierce: So for the people who do go across the border, you were talking a little about the medical record. We've had multiple guests on about this recently. Brady's coming to mind...

Jeremy Carr: Guava is also coming to mind.

Heather Pierce: Exactly. And Connect for Patients, a pretty new app. It's basically a health record in an app that pulls your medical data from everywhere, and it's pretty amazing. So when people go over the border and likely pay cash, what happens? Do they get documentation of their medical records to bring back and share with their doctors? I'm going to guess the Mexican facilities are definitely not part of the national EHR systems.

Kelli Frias: They aren't. So patients become responsible for traveling back with that record. Particularly with prescriptions, they're responsible for identifying whether there could be conflicts between medications. We've seen people with a note on their phone that says, "These are all the medications I'm taking," and they'll show it to the provider in Mexico and ask whether there are any contraindications. It leaves much of that responsibility on the patients. One person we met with said, "I feel like a ghost." I think that was really telling. Half my records are here, half my records are there, because I can't get all my care in the U.S., so I don't really feel like I have a record anywhere. And in reality, you don't.

Heather Pierce: Yeah. If it's not all there, it's not really a record.

Kelli Frias: Yes.

Heather Pierce: And to add to that, something I wanted to make sure we talked about is GLP-1s, and the other things you can get at the farmacia, as it's called. I can't tell you how many times I've been in Rocky Point or other Mexican cities where pharmacies are everywhere and the guys stand outside like salesmen trying to get you in the door. If anyone listening has experienced that, you know. They've got Viagra, they've got all the things. What did you learn about that? Maybe let's talk about GLP-1s specifically, since that's such a hot topic in the news right now.

Kelli Frias: I think the GLP-1 space is really interesting because the same kind of thing is happening. People are stepping outside their traditional provider network and seeing a physician, nurse practitioner, or some other provider online, and getting their GLP-1 prescription outside that network. So they're responsible for telling their provider, "Hey, I'm on a GLP-1, you need to be aware of that." So we're seeing more of that consumer shopping than we have in the past.

We certainly saw it happening in Mexico, particularly when GLP-1s were in shortage in the U.S. and people were going into Mexico for them. And there were some real concerning issues. Some people would split the dose. They'd say, "My dose is X, but to save costs I'll share this medication with a friend and we'll each take half." We saw some of that. We saw people taking the medication who had really poor side effects as a result and struggled with that. And then who do you go to for help navigating that? Some providers in the U.S. were wonderful about talking with patients. They knew their patients were going to cross, so they made the best of it. Others absolutely didn't want to hear it, so those patients had no conversations with their provider.

Jeremy Carr: Is it still effective when you split medication like that? Is that even useful?

Kelli Frias: I think it depends on what it's for. We didn't ask about that piece so much. It was more: what made you decide to do that? There was a sense that something was better than nothing, and an element of "I'm here, why not?" You have this new access to an entire system of medications you obviously wouldn't have in the U.S., and it's so easy. That's part of it too. It's such a difficult process in the U.S. that it feels really good to go into Mexico and access care immediately. We should have that, but we don't. So there's something really rewarding about that immediate access.

Heather Pierce: And again, I don't know if this is something you can answer, but did you see or learn in your research whether the medications you can buy in Mexican pharmacies are just as safe as what you can buy across the border in the States?

Kelli Frias: We didn't do any systematic assessment. I know there's research that has done those kinds of assessments, and for the most part, yes. What we heard from patients is that if you're buying at a traditional pharmacy, not from someone on the street, and the medication is labeled in Spanish, you're fine. That's another thing: if you're buying it and it's in English, that's probably a bad prescription. There are a couple of branded pharmacy chains there, and Walgreens is another option, and people said they absolutely went there for all their medications with no problem. I'm thinking of other examples of folks who needed prescriptions, antidepressants for example, who also regularly went into Mexico with no problems.

Heather Pierce: Okay, that's good. I kind of assumed they were safe. I remember for many years, probably back in the '90s and 2000s, everyone would go get Somas in Mexico. I never personally did it. I just remember people talking about it. I don't know if that was a thing back then, or maybe just the crowd I was hanging out with.

Kelli Frias: I assume there's a whole host of different reasons people go. I will say what's interesting is we found people who would specifically go buy their Tylenol in Mexico. We're talking about packaged Tylenol sold at Walgreens or another pharmacy. Going back to the psychological piece, they felt the Tylenol in Mexico worked better than the Tylenol in the U.S. We heard that over and over again, and it was so interesting. It's a brand name. It's the same thing.

Heather Pierce: It's just like Mexican Coke is better. Come on, we all know that.

Jeremy Carr: Well, that actually has different stuff in it. Mexican Coke is good because it doesn't have high-fructose corn syrup.

Heather Pierce: I know, it is so good.

Jeremy Carr: You can define the difference there. There's no difference in the Tylenol. Tylenol is Tylenol. It's the same package from the same company. I don't know, good vibes in Mexico? Wow, the psychology. I never realized the divergent psychologies of which side of the border you're on when you get your healthcare. This is kind of fascinating.

Kelli Frias: It really is. I'll give another example that blew my mind. We were in El Paso walking into Juárez, probably back in 2021. We were crossing the bridge, all outside, and I was standing in line when several people in front of me started putting masks on. I asked, "Why are you putting a mask on here? We just crossed 50 feet, and we're still outside." And they said, "In Mexico, we take care of each other." It was so striking. Just by crossing, and we didn't go inside, we were still outside, people shifted their behavior once they walked into Mexico. I found that really intriguing.

Heather Pierce: Wow. That is thought-provoking.

Jeremy Carr: So does it go both ways? They cross the border the other way and think, oh, I don't have to care about anybody anymore, because I'm an American now? Is that really how you want to live your life? Do you want to change your principles based on which side of the border you're on? Shouldn't you still be a nice person? Shouldn't you still do that?

Kelli Frias: Yeah. I'm just saying, right? This is interesting. We also saw the same thing with people driving differently. There are Uber-type services where people will take you across, take you to all the different places, and drive you back. I said to one driver, "It seems like you're driving differently now that we're in Mexico." And he said, "Oh, yeah. We're in Mexico now. I have to drive differently."

Jeremy Carr: That is kind of a thing, though. Even driving from Flagstaff to Phoenix, once you get there, you have to drive differently.

Heather Pierce: That's true.

Jeremy Carr: You cannot drive in Phoenix the way you drive in Flagstaff, and vice versa. If you drive like you're in Flagstaff when you're in Phoenix, you're going to get run off the road. If you drive like you're in Phoenix when you're in Flagstaff, you're going to drive off the road, because the roads are too small and windy. You're going to end up in the woods.

Heather Pierce: That's right.

Kelli Frias: It's a different hazard.

Heather Pierce: It's a very different thing. Okay, this is absolutely fascinating stuff. Cross-border healthcare is so interesting.

Jeremy Carr: Remember that Tylenol part? They think the Tylenol works differently because of which side they're on. To me, that's the whole thing in a nutshell.

Heather Pierce: Yep. Who knew? So, with cross-border healthcare, I want to start wrapping up our conversation. This goes by fast. Time flies when you're having fun, and we have fun here at the Uprising.

With things changing in U.S. healthcare in general, and without getting too deep into what's happening in the world, universal healthcare, Medicare for All, however you want to call it, is getting a lot of attention right now, and I think that's going to continue to grow. That's not to say we'll ever get there, though I do hope we do. But employer-provided health plans cover about 50% of Americans, I think, something like that?

Kelli Frias: Maybe a little bit higher.

Heather Pierce: Yeah, I think you're right. Either way, it's a lot. And there are some problems with that model. People move between jobs so often nowadays, and companies change insurance carriers sometimes every few years. That's a big problem for preventive care in particular. Why invest all this money in preventive care when you're going to be gone in two years and my investment won't matter to me in the end? But I don't think employer plans will ever go away. I still think they have a place. You've talked about multinational plans. From the work you've done and are doing, what do you think we might see in this space five years from now, or even longer?

Kelli Frias: Interesting. I think we're going to ask consumers to be more proactive about their health, and I don't know that that's a bad thing. That consumer-driven model, where we ask consumers to do more shopping, I think is good. I'm not a proponent of giving over access to your body to anyone other than yourself, and certainly not to any political party. So I think that's part of it.

I also think we may see more employer-sponsored networks where your employer is actually providing your care. I wonder how much we need third-party administrators and insurance companies to facilitate care if what we're talking about is more local access to care. I'd be interested to see what that might look like.

I also think we're probably going to need someone to step in and say that hospital systems can't continue to merge at the levels they are now. There's a huge imbalance of power in the marketplace, and I don't know that any stakeholder can maneuver around that, at least at this point. So those are all things we need to be thinking about.

Jeremy Carr: America loves monopolies. Don't let them tell you any different.

Heather Pierce: This is true. One thing I just thought of, as you were talking about employer-provided care: we had Blake Madden from Hospitalogy on the show. He runs a newsletter. I don't know if you're familiar with it, but you should check it out; it's very informative. He talked about an example, I believe in upstate New York, of a really large employer working with a very large regional health system to eliminate the insurance carrier entirely. They essentially created a direct healthcare plan.

It reminds me a lot of what was happening when I worked in this space around 2009 and 2010. I worked for Aetna, and Aetna as an insurance carrier was setting up what they called joint-venture health plans, or even accountable care organizations, with health systems. They would offer that plan to employers in a specific market, and if you chose it, it was all about steerage, through cost, access, and other things. If you got all your care through the health system itself, it was like a tier-one arrangement, and you'd get much lower rates. I think that was all part of the value-based care world. I don't think they executed it as well as the idea deserved.

Kelli Frias: Yes.

Heather Pierce: It keeps coming up. But I loved the example Blake shared, of an employer going straight to a health system that had all the facilities, the specialists, the urgent cares, all the things, cutting out the insurance carrier entirely and contracting directly with their own set of rates.

Jeremy Carr: That's interesting. It seems set up to create a different set of problems, though, if you let employers directly run the actual healthcare side of it.

Heather Pierce: You're not wrong.

Jeremy Carr: I can see Amazon having its own clinics, and I can only imagine the mistreatment people would get there because Amazon is running them. You know what I mean?

Heather Pierce: Right. Sometimes having that neutral party involved is needed.

Jeremy Carr: The employer providing your insurance is one thing, but directly providing the actual healthcare? I honestly think it would be worse in a lot of ways.

Heather Pierce: I feel like I lean that way too. I feel like I need to look into that particular example a little more. It'd be interesting to see how it's actually operating.

Jeremy Carr: Like anything else, there are probably really good ways to do it, and with the right company it will be fine. But with a lot of companies, it's not going to go that way.

Kelli Frias: I agree. There are some real concerns when you essentially shift the balance of power to the employer. But at the same time, I'm also worried about how small businesses will survive if the cost of healthcare is so high for their employees and their families. I don't have a good answer to that. We're in a place where we're setting up large corporations to continue to succeed while smaller companies really struggle.

Heather Pierce: Most small businesses can't afford insurance for their employees, or themselves, now anyway. I know that because my husband owns one.

Jeremy Carr: If we socialized medicine, we wouldn't have to worry about that anymore.

Heather Pierce: That's why I'd like to see universal healthcare, like everybody else has. I would love for that to come here someday.

Jeremy Carr: It would be nice. I'm going to say it every time.

Kelli Frias: And everything we've been talking about describes a healthcare system where quality is getting worse. We're paying more and more, and we're not getting the quality. At the same time, all this innovation, AI in healthcare and so on, is supposed to make treatment plans and experiences better, and the care isn't getting better.

Jeremy Carr: Because now they're using AI to deny insurance claims. That's how they're using AI. Instead of helping, they're using it to deny people.

Kelli Frias: I think that's another piece of this. We can use it for good or we can use it for evil. It's not the tool.

Jeremy Carr: Right. It's not the AI tool itself that matters. It's the people wielding it and what they're using it for, because it can do so many things. That's really the thing with AI. In itself, it's just something we made. It's all about how you use it. It's the old hammer analogy: you can build things with a hammer, and you can break things with a hammer. AI is the same.

Heather Pierce: So, you're going to get into more research around dental. And do you think your research will keep expanding into this cross-border medical space as things evolve over the coming years? Is that something you'll keep coming back to?

Kelli Frias: We're working on a couple of projects right now. One is that I'm really interested in medical influencers. As you might imagine, most of us take our medical advice from social media, and most of the people giving that advice aren't trained medical professionals. Oftentimes we trust them more than we trust medical professionals. So I'm very interested in that space.

I've also been doing some work on pain and pain management, and how we make trade-offs between psychological pain, meaning the financial pain of paying for healthcare, and how that affects our perceptions of physical pain. I just published a paper in that space, and I'll continue working on it in the coming years.

Heather Pierce: You'll have to share any links with us so we can put them in the show notes and point listeners to your work. I think it's fascinating: the human behavior piece, the psychology of literally crossing the border, the way you might look at a busy waiting room. That just blows my mind. But then I think, oh my God, that makes so much sense too.

Kelli Frias: Yes. We're complex creatures, but at the same time we do a lot of weird things.

Heather Pierce: We do, for sure. Very dichotomous, we are. Well, this has definitely been... we've never had a professor on the show.

Jeremy Carr: We've had doctors, but not like this.

Heather Pierce: Not like this. We've had some pretty interesting conversations, but we've never really talked about medical tourism, so we're checking a few boxes today with this conversation. I'm really excited.

Jeremy Carr: And I think this is about our 111th episode, and we're still finding new stuff. That's pretty cool.

Kelli Frias: I feel honored to be your first professor.

Heather Pierce: Yes, I love it. Thank you so much for coming on. This has been a great conversation. We'll have to have you back after you do more of this research and have more findings and more ways to blow our minds.

Jeremy Carr: We'd love to hear it. Get a yearly update, next summer or something.

Kelli Frias: Happy to. That's a lot of fun. I appreciate it, and you're doing amazing work. Somebody has to be having this conversation.

Heather Pierce: That's what we're trying to do. We just need more people listening, so tell all your friends.

Jeremy Carr: Awesome. Thanks for joining us on Healthcare Uprising. Make sure to hit those like and subscribe buttons before you go, and take a moment to think of a friend and hit that share button. You can find us on all the major audio platforms, and we've got video on YouTube if you want to watch us in action.

Heather Pierce: You can also find us on social media on LinkedIn, TikTok, and Instagram. Just search "Healthcare Uprising" to find us. If you're a new company with a cool new product, if you're innovating alternative methods in the health and wellness space, or if you have a personal healthcare journey you'd like to share with us here at the Uprising, email us at healthcareuprising@gmail.com, and we'll get back to you about coming on the show. Well, that's all for this dose of Healthcare Uprising. Until next time, keep looking for the good in the world, because sometimes it's where you least expect it.

Jeremy Carr: We are not doctors, and we don't play one on TV. If you need medical advice, consult your physician or a healthcare professional. This has been a Shut Up Production.