PLANYC 2030

 

When Mike Nugent flies, nothing annoys him more than settling into his seat, the plane taking off, and the passenger in front reclining into his lap. So he’s come up with a solution.

“I put my knee right in the middle of the back of the seat,” Nugent, 66, says. “They think it’s broken. They try (to recline) two or three times, then they give it up.”

Nugent, a hospital laundry consultant who’s on the road most days of the year, has another way to sidestep the irritation that can accompany flying. “I’ve started to drive as often as I can,” he says.

Long gone are the days when air travel was an elegant experience. Many road warriors say that courtesy, at the airport or on the plane, is becoming about as rare as a free, hot in-flight meal. They grouse that inconsiderate, or downright rude, behavior is more common and that it’s spurred by an increasing discomfort with all aspects of flying, from security rules to bare-bones service, that put travelers on edge.

And behavior is unlikely to get better, some involved in the travel industry say, because irritants such as extra airline fees and more crowded planes aren’t going away soon.

“The flying experience is terrible,” says Anne Banas, executive editor of SmarterTravel.com. “You’re getting less legroom. People fight over things like capacity in overhead bins. Airlines are charging bag fees. … Airlines are doing things that are making it more difficult and uncomfortable for the passenger, and the customer service isn’t getting that much better. You compound those factors, and you have a lot of frustration in the air.”

Frustration can lead to bad manners.

“So much of etiquette is based on knowing what to expect from someone else,” says Lizzie Post, spokeswoman for the Emily Post Institute, which was founded by manners maven Emily Post and is dedicated to the promotion of etiquette.

Passengers, she says, “don’t know how long that security line is going to be. They don’t know if they have anything in their bag that will meet regulations in this airport but not that airport. The nerves get up, and that’s when we lose our awareness of the other people around us.”

Frustrations add up

Complaints abound. Road warriors fret about parents who won’t quiet screeching toddlers, the guy who had garlic for lunch and won’t stop talking, and supersized seatmates who intrude on their space. They speak of dirty planes, testy flight attendants and loud passengers who won’t turn off their cellphones.

There’s the lady trying to stuff a steamer trunk into an overhead bin in the front of the cabin when her seat is in the back, and the passengers who give you whiplash dragging your seat down to pull themselves up.

And there can be a healthy dose of aggravation before you even board the plane, frequent fliers say, such as security screening rules that vary depending on the airport and flights canceled at the last minute with little explanation.

“I don’t care whether it’s a Big Mac or a Subway sandwich, the food smells gross in a confined place,” Margaret Bowles, a lawyer in Tampa, complained in an e-mail. “If you are going to eat a sandwich, get one that isn’t cooked and doesn’t have onions or peppers.”

“There needs to be a flying etiquette pamphlet handed out to anyone who takes less than three trips per year,” writes frequent flier Faith Varwig.

Sometimes, behavior goes from merely discourteous to disruptive, and flights are diverted.

On July 10, a Southwest flight heading to Islip, N.Y., from Orlando was diverted to Raleigh, N.C., when a passenger began using foul language and became verbally abusive to the flight crew, says Paul Flaningan, a Southwest spokesman. In another incident this month, a Southwest flight from Chicago to Salt Lake City was diverted to Denver when a passenger began to act erratically and refused to sit down.

Travelers aren’t just finding fault with the behavior of fellow passengers. A national Consumer Reports survey released in May found airline passengers were most annoyed by ubiquitous fees airlines charge to check a bag. On a scale of 1 to 10, with 10 being the most vexing, bag charges scored an 8.4. Other fees, for such items as blankets, scored 8.1, while unhelpful airline workers got a 7.7.

More stressful flying

A decline in manners can be tied in part to a flying experience that’s more stressful as security has intensified after the terror attacks of Sept. 11. And many airlines have cut service and added fees to make ends meet, some industry observers say.

Flying may get more stressful as people who’d put travel on hold during the economic downturn return to the air and find smaller planes and fewer available flights.

“Planes are flying more passengers,” says Corey Caldwell, spokeswoman for the Association of Flight Attendants. “There’s less available seats … in a stressful environment and a very close environment. A lot of times there are disruptions that do occur.”

Unruly behavior on the part of passengers “has heightened since 9/11, and we often see spikes when there’s a new implementation of a rule or policy or procedure,” Caldwell says. “(It’s) really because these passengers are being exposed to more and more stressors.”

Attendants are under more pressure, she says.

“Flight attendants are having to be vigilant on a lot more fronts than they have before, and so after a 14- or 16-hour day, I think anyone is a little more stressed,” she says.

Paul DeStefano, who travels two or three times a week, has a couple of peeves. One is flatulence.

“It is something that just infuriates me,” says DeStefano, 43, of Bridgewater, N.J. “We’re all human, but you’re stuck in a tube with somebody for four hours and they have the audacity to think it’s OK to let it loose.”

DeStefano, who runs the sales force of a consumer products business, says he’s also bothered by the sight of men who won’t help elderly women or mothers who are struggling with their bags.

“You should fly as though your mother’s with you,” he says. “Would she expect you to pass gas? No. Would she expect you to get the bag? Yes.”

Larry Stocker, a frequent flier, has a list of retorts at the ready.

For the fellow passenger who hasn’t bathed, “I’ll just say. ‘Do you use a deodorant?’ ” For the guy yelling into a cellphone, “I say, ‘This is a really interesting conversation. Could you tone it down because I’m trying to take a nap.’ “

Stocker, 58, who is president of his own company, says he wasn’t always so forward. But boorish behavior by fellow passengers is “so much more prevalent today … you can almost feel like you’re forced to take some action on your own behalf.”

New nuisances

Some irritants, such as the kid constantly kicking the back of your seat, have long been traveling pitfalls. But the digital age has ushered in new nuisances.

Peter Juhren, 52, who travels 175,000 miles a year for his job, says he’s had to ask passengers to more gently tap the console on the back of his seat. “Sometimes you get somebody behind you, especially when they’re playing a game … and they’re just pounding away,” says Juhren, a corporate service manager for a construction equipment business, who lives in Salem, Ore.

Pauline Weaver says she once had to admonish a fellow flier who kept texting long after passengers were told to stop.

“I tapped her on the shoulder, and I said, ‘You’ve got to turn it off or I’m going to tell the flight attendant,’ ” says Weaver, 61, a lawyer based in Hayward, Calif. “I don’t know from a hill of beans whether (the portable device) would have impacted the plane, but I don’t really care. You’re just not supposed to do it. … If you want to fly, you have to follow the rules. If you don’t want to, take a train.”

Industry observers and etiquette experts say there are some behaviors that you just have to make your peace with when you’re sharing a cramped, public space.

But there are ways to deal.

“People ask us all the time how do you combat the rudeness,” Lizzie Post says. “I go out there, and I’m one less rude person. You consider things. I’m not going to bring my really smelly fish leftovers on the plane. I’m going to bring a turkey sandwich.”

Travel experts say that you can ask the person behind you if it’s OK to recline your seat, recline only halfway or for part of the flight.

Bring along headphones to block out noise, and it’s fine to politely inform a seatmate that you’re not in the mood to chat.

Airlines, on the other hand, should look at courtesy and customer service as a matter of dollars and cents, says Stuart Greif, vice president and general manager for global travel and hospitality for J.D. Power and Associates.

A J.D. Power survey released last month found that passenger satisfaction with North American airlines was up but still below the levels that existed before the widespread implementation of fees. And Greif says satisfaction continues to lag behind other industries, such as autos or insurance.

“Ultimately, those that make their customers happy and feel valued … are the ones that are going to earn more revenue and be here in the long term,” Greif says of airlines.

Despite all the frustrations that can crop up, frequent flier DeStefano says he still manages to see the bright side.

“I still get a little kick in the pants every time the airplane gets off the runway,” he says. “You’re taking a plane full of … people at 500-plus miles an hour, going a time zone away.

“The fact that it works as well as it does is amazing.”

 

 

When John McNally needed a knee-replacement operation, his employer, Alpha Coal West, offered to pay his travel expenses if he would have the surgery in Fort Collins, Colo., a five-hour drive from his home near Gillette, Wyo.

The Colorado surgery center had data showing good results with such operations, and it charged far less than the hospital in Gillette. Despite feeling “every bump on the way back,” McNally was so pleased with the outcome of the operation that he returned to Colorado a few months later to have his other knee done.

Forget about traveling to Thailand or India for low-cost surgery. More employers and insurers are offering financial incentives to encourage workers like McNally to consider “domestic medical travel.” By steering workers to facilities with high-quality care and lower prices, employers say they can reduce their costs 20% to 40% — more than enough to cover the travel expenses.

A lot is at stake. Hospital care accounts for more than one-third of the nation’s $2.5 trillion annual health spending tab. And spending on hospital care — which rose nearly 6% last year — is expected to accelerate, government data show, driven both by increased use and rising prices. Employers with domestic travel programs say they save money in part by negotiating a single rate, which includes fees for surgeons, anesthesiologists and all medical care up until the patient is discharged.

“This is one of our ways of trying to bend the cost curve,” says Bob Ihrie, senior vice president in charge of employee programs at Lowe’s. The national home-improvement retailer has a three-year deal with the Cleveland Clinic to send willing employees and their dependents there who need treatments such as open-heart surgeries, valve repairs and pacemakers. Lowe’s, which like most large employers is self-insured, may add orthopedic surgeries to its travel program, Ihrie says. Four other large employers — including an airline and a bank — are in a coalition with Lowe’s that may soon announce similar agreements with medical providers, he says.

Lower costs, better care

If domestic medical travel catches on, particularly among large employers, it could help drive down costs and improve the quality of care, Ihrie says.

It could shake up the hospital industry by fostering “a truly national competition,” says consultant Jim Unland of the Health Capital Group in Chicago.

The move by Lowe’s — along with growing interest in domestic medical travel by other employers — comes amid scrutiny of the role hospital prices and their market clout play in rising health insurance premiums, along with wider awareness that medical costs and quality can vary dramatically between hospitals and across regions.

Employers and insurers have long sent patients to “centers of excellence” for organ transplants and other complex procedures. But domestic travel is moving beyond that to offer more types of medical care, including back and cardiac-bypass surgeries, and even relatively minor treatments, such as repairs to knee cartilage. Some companies are even providing financial incentives to workers.

Among the firms promoting domestic travel:

•Alpha Coal West, McNally’s employer, says its medical costs have remained flat — even as spending nationwide has risen — since its 2001 decision to offer medical travel to its Wyoming workers and their families. A division of Alpha Natural Resources, the nation’s third largest coal-mining firm, Alpha Coal offers travel to Fort Collins; Billings, Mont.; Rochester, Minn.; and Houston for medical care related to orthopedic problems, cancer and other difficult diseases.

•BridgeHealth Medical, based in Greenwood Village, Colo., began offering domestic travel programs to small and midsize employers last year. The firm links workers to a network of about 20 hospitals and surgical centers in the U.S., where it has negotiated prices for orthopedic, cardiac and other types of surgery.

•The Health Services Coalition, a group of 24 employers and unions in Las Vegas, warned in May that its member organizations might send some of their 260,000-plus employees and dependents to hospitals in Utah or California unless local hospitals provide plans to improve quality of care and reduce costs.

Still, the domestic travel movement faces challenges. It could backfire, Unland says, if employers and insurers focus solely on cost, rather than quality. While most programs are voluntary, large financial incentives can blur the line between choice and necessity. Medical providers have balked at making their discounts public. And it isn’t clear how many workers are willing to travel long distances, particularly those with young children.

“Never mind sending them to India, they don’t even want to go to Oklahoma,” says Rick Baker, president and CEO of North American Surgery, a Vancouver, Canada-based firm that negotiates discounted surgeries in the USA for individuals who don’t have health insurance. While uninsured people are willing to travel, workers with insurance are less likely to hop on an airplane, he says.

Some insurers not on board

Insurers also can be reluctant to encourage domestic travel. Lowe’s Ihrie says he asked the insurers who administer benefits for his firm’s 125,000 employees to develop ways for workers to determine the best hospitals for cost and quality. Years went by without the insurers taking action. “So we went out and did it ourselves.”

So did Alpha Coal. It hired retired surgeon David Crowder to research options outside its local area for some types of care, says Michael Peelish, executive vice president at Alpha Natural Resources. Using data from Health Grades, a publicly traded hospital-ratings firm, and other sources, Crowder looked into the quality of care at facilities around the country.

“It was really about looking for the best in breed,” Crowder says.

Alpha negotiated rates for specific treatments with medical centers on Crowder’s list, including Orthopaedic & Spine Center of the Rockies in Fort Collins, where McNally went.

Alpha Coal’s insurance program reduces co-insurance payments from 20% to 10% for workers willing to travel. It also covers hotel and travel costs for employees and their spouses or partners.

“I would have probably been in a wheelchair by now if I hadn’t done the surgeries,” says McNally, a welder who returned to work for two years after his surgeries in 2007. He is now retired and has no problem with his company saving money on his care.

Savings result not only from lower prices but from fewer complications with procedures done at high-quality centers, Crowder says. Some follow-up care, including physical therapy, is provided in Gillette.

In fact, all the travel-for-surgery programs offer emergency follow-up care for patients. If any worker who travels for surgery has a complication or other urgent problem after returning home, that treatment is provided at the local hospital and covered under the company’s regular insurance plan, the companies say.

In Lowe’s case, the company negotiated flat-rate fees with the Cleveland Clinic for complex cardiac procedures. Lowe’s is not charged extra if a patient is re-admitted to the clinic for care resulting from the surgery. But Lowe’s agreed to make additional payments for patients whose medical needs are so complex that they exceed normal ranges, such as a patient who might have multiple problems. Even those cases show savings, Ihrie says.

Already, one Lowe’s employee had three complex heart procedures while hospitalized under the new program, Ihrie says. Lowe’s asked benefit firm Mercer to calculate the cost of those procedures if they were done under the company’s standard insurance plan. Mercer estimated $531,000. Under the agreement with the Cleveland Clinic, Lowe’s paid $469,000, Ihrie said.

Less costly for employees, too

To encourage workers to use the program, Lowe’s waives deductibles and covers their travel and hotel costs.

Those savings made the decision a no-brainer for Tony Reynolds, an eight-year employee based in Dover, Del., who needed mitral-valve surgery.

Reynolds, 50, knew the company would waive $5,000 in deductibles and he’d save in other out-of-pocket costs if he went to Cleveland, and that Lowe’s would cover travel costs for him and his wife. Reynolds, who had his surgery last week, has been discharged from the hospital, is staying at a local hotel, and is scheduled to fly home Thursday.

Simpler treatments are also covered under some work-based travel programs.

Barry Yontz, 58, a sales manager in Rockton, Ill., flew to Southern California for outpatient arthroscopic surgery to repair cartilage in his knee. BridgeHealth arranged the trip. Even after paying for travel and hotel costs for him and his wife, the insurance company “saved almost $3,000″ compared with a similar surgery he had the previous year near home, Yontz says. This is completely independent from in-state California health insurance quotes.

Nationwide, it’s hard to quantify how many employers are embracing domestic medical travel — or how much money they’re saving, says Paul Keckley, executive director of the Deloitte Center for Health Solutions, who has studied medical travel extensively.

Employers who are going to send patients “hundreds or thousands of miles” for care need to evaluate whether “the outcomes are truly, dramatically better,” says consultant Peter Hayes with Health Care Solutions in Scarborough, Maine, whose clients include employers, drug companies and other industry players.

Most major metropolitan areas have an “outstanding hospital” nearby, says Victor Lazzaro, CEO of BridgeHealth. “Their outcomes are fabulous, and they have excess capacity.”

Domestic travel is “slowly catching on,” says Hayes, whose last job was heading employee benefits for supermarket chain Hannaford Bros. in Scarborough. Three years ago, the company began offering its 27,000 workers the option of going overseas for some expensive surgeries. No one went because local hospitals lowered their prices in response.

Still, insurers are reluctant to offer travel incentives because “it really angers the (local) provider community” to send patients elsewhere for care, Hayes says.

James Caillouette, co-owner and surgeon at the Newport Orthopedic Institute in Newport Beach, Calif., says doctors and hospitals had better get over their anger and embrace the new model. Two years ago, the center began signing flat-rate prices with domestic travel companies.

“That’s where health care is heading,” Caillouette says. “We’re no longer going to be paid piecemeal.”