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Grace said she and Staab have no regrets and would return to India for care. But coordinating the care and the trip was complicated. "I had to sort of bushwhack my way through it," Grace said. "People without my stamina for research would have given up."

There is no charge for IndUShealth's assistance with care, which will include connecting patients with an Indian physician via video teleconferencing, and travel arrangements. The company's revenue will come from its two Indian hospital partners, Indraprastha Apollo Hospital New Delhi and Escorts Heart Institute and Research Center. They will pay IndUShealth a fee for the business it refers.

"What we are doing saves them from having to deal with the patient on the front end," said Rao, a former software executive.

IndUShealth, formally launched in September, is working with a handful of patients but none has yet traveled to India for care. Perhaps the biggest challenge the company and its Indian hospital partners face is assuring U.S. patients that they will receive quality care.

Even IndUShealth's chief medical officer, Dr. C. Franklin Church, needed convincing when Rao and Keesling came to him with their idea. "My image of India was ... Mother Teresa with the unwashed poor," said Church, a family physician and a former medical director for United Healthcare of North Carolina. "I was very skeptical we could get first-class health care in a Third World country."

Then Church accompanied Rao and Keesling, a former hospital CEO who ran facilities in Kentucky and Michigan, to New Delhi to tour the two hospitals and meet surgeons and administrators.

The facilities were state-of-the-art and immaculate, Church said. He spotted medical technology that is only starting to appear in North Carolina hospitals. He noted that Apollo this year became the first hospital in India to achieve accreditation by the Joint Commission International, a branch of the leading hospital-quality oversight body in the United States.

Church learned that most physicians on staff were educated and board-certified in the United States. Dr. Naresh Trehan, who founded Escorts in 1988, was a top heart surgeon in Manhattan and a New York University professor before returning to practice in India. He did Howard Staab's surgery.

"Once people understand that it's not a compromise in care, that you're not just going to save money, I think the gates will be open," said Grace.

She still doubts anyone would travel halfway around the world unless it was necessary. "Right outside [the hospital], you don't eat the food, you don't drink the water, there are cows in the road and they have the right-of-way," said Grace. "It's not for the light-hearted."

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