Medical Tourism

Medical tourism (also called medical travel, health tourism or global healthcare) is a term initially coined by travel agencies and the mass media to describe the rapidly-growing practice of travelling across international borders to obtain health care. It also refers pejoratively to the practice of healthcare providers travelling internationally to deliver healthcare.[1][2]

Services typically sought by travelers include elective procedures as well as complex specialized surgeries such as joint replacement (knee/hip), cardiac surgery, dental surgery, and cosmetic surgeries. However, virtually every type of health care, including psychiatry, alternative treatments, convalescent care and even burial services are available.

Over 50 countries have identified medical tourism as a national industry.[3] However, accreditation and other measures of quality vary widely across the globe, and some destinations may become hazardous or even dangerous for medical tourists.

In the context of global health, "medical tourism" is a pejorative because during such trips health care providers often practice outside of their areas of expertise or hold different (i.e., lower) standards of care.[4][5] Greater numbers than ever before of student volunteers, health professions trainees, and researchers from resource-rich countries are working temporarily and anticipating future work in resource-starved areas.[5][6] This emphasizes the importance of understanding this other definition.

Contents
1 History
2 Description
3 Process
4 International healthcare accreditation
5 Organizations and Associations
6 Risks
6.1 Legal issues
6.2 Ethical issues
7 Employer-sponsored health care in the US
8 References

History

The first recorded instance of medical tourism dates back thousands of years to when Greek pilgrims traveled from all over the Mediterranean to the small territory in the Saronic Gulf called Epidauria.[citation needed] This territory was the sanctuary of the healing god Asklepios. Epidauria became the original travel destination for medical tourism.

Spa towns and sanitariums may be considered an early form of medical tourism. In eighteenth century England, for example, patients visited spas because they were places with supposedly health-giving mineral waters, treating diseases from gout to liver disorders and bronchitis.[3]

Description

Factors that have led to the increasing popularity of medical travel include the high cost of health care, long wait times for certain procedures, the ease and affordability of international travel, and improvements in both technology and standards of care in many countries.[7]

Many surgery procedures performed in medical tourism destinations cost a fraction of the price they do in the First World. For example a liver transplant that cost $300,000 USD in America cost about $91,000 USD in Taiwan.[8] A large draw to medical travel is convenience and speed. Countries that operate public health-care systems are often so taxed that it can take considerable time to get non-urgent medical care. Using Canada as an example, an estimated 782,936 Canadians spent time on medical waiting lists in 2005, waiting an average of 9.4 weeks.[9] Canada has set waiting-time benchmarks, e. g. 26 weeks for a hip replacement and 16 weeks for cataract surgery, for non-urgent medical procedures.[10]

Medical tourists come from a variety of locations including Europe, the Middle East, Japan, the United States, and Canada. Factors that drive demand for medical services abroad in First World countries include: large populations, comparatively high wealth, the high expense of health care or lack of health care options locally, and increasingly high expectations of their populations with respect to health care.

In First World countries like the United States medical tourism has large growth prospects and potentially destabilizing implications. A forecast by Deloitte Consulting published in August 2008 projected that medical tourism originating in the US could jump by a factor of ten over the next decade. An estimated 750,000 Americans went abroad for health care in 2007, and the report estimated that a million and a half would seek health care outside the US in 2008. The growth in medical tourism has the potential to cost US health care providers billions of dollars in lost revenue.[11]

An authority at the Harvard Business School recently stated that "medical tourism is promoted much more heavily in the United Kingdom than in the United States".[12]

Additionally, some patients in some First World countries are finding that insurance either does not cover orthopedic surgery (such as knee/hip replacement) or limits the choice of the facility, surgeon, or prosthetics to be used. Medical tourism for knee/hip replacements has emerged as one of the more widely accepted procedures because of the lower cost and minimal difficulties associated with the traveling to/from the surgery. Colombia provides a knee replacement for about $5,000 USD, including all associated fees, such as FDA-approved prosthetics and hospital stay-over expenses. However, many clinics quote prices that are not all-inclusive and include only the surgeon fees associated with the procedure.[13]

According to an article by the University of Delaware publication, UDaily:

“The cost of surgery in India, Thailand or South Africa can be one-tenth of what it is in the United States or Western Europe, and sometimes even less. A heart-valve replacement that would cost $200,000 or more in the US, for example, goes for $10,000 in India--and that includes round-trip airfare and a brief vacation package. Similarly, a metal-free dental bridge worth $5,500 in the US costs $500 in India, a knee replacement in Thailand with six days of physical therapy costs about one-fifth of what it would in the States, and Lasik eye surgery worth $3,700 in the US is available in many other countries for only $730. Cosmetic surgery savings are even greater: A full facelift that would cost $20,000 in the US runs about $1,250 in South Africa.[13]”

Popular medical travel worldwide destinations include: Argentina, Brunei, Cuba, Colombia, Costa Rica, Hong Kong, Hungary, India, Jordan, Lithuania, Malaysia, The Philippines, Singapore, South Africa, Thailand, and recently, Saudi Arabia, UAE, South Korea, Tunisia, Ukraine, and New Zealand.[3]

Popular cosmetic surgery travel destinations include: Argentina, Bolivia, Brazil, Colombia, Costa Rica, Cuba, Mexico, Turkey,and Ukraine. In South America, countries such as Argentina, Bolivia, Brazil and Colombia lead on plastic surgery medical skills relying on their experienced plastic surgeons. In Bolivia and Colombia, plastic surgery has also become quite common. According to the "Sociedad Boliviana de Cirugia Plastica y Reconstructiva", more than 70% of middle and upper class women in the country have had some form of plastic surgery. Colombia also provides advanced care in cardiovascular and transplant surgery.

In Europe Belgium, Poland, Slovakia, and Ukraine are also breaking into the business. South Africa is taking the term "medical tourism" very literally by promoting their "medical safaris".[14]

A specialized subset of medical tourism is reproductive tourism and reproductive outsourcing,[15] which is the practice of traveling abroad to undergo in-vitro fertilization, surrogate pregnancy and other assisted reproductive technology treatments including freezing embryos for retro-production.[16]

However, perceptions of medical tourism are not always positive. In places like the US, which has high standards of quality, medical tourism is viewed as risky. In some parts of the world, wider political issues can influence where medical tourists will choose to seek out health care.

Health tourism providers have developed as intermediaries to unite potential medical tourists with provider hospitals and other organisations. Companies are beginning to offer global health care options that will enable North American and European patients to access world health care at a fraction of the cost of domestic care. Companies that focus on medical value travel typically provide nurse case managers to assist patients with pre- and post-travel medical issues. They also help provide resources for follow-up care upon the patient's return.

Process

The typical process is as follows: the person seeking medical treatment abroad contacts a medical tourism provider. The provider usually requires the patient to provide a medical report, including the nature of ailment, local doctor’s opinion, medical history, and diagnosis, and may request additional information. Certified medical doctors or consultants then advise on the medical treatment. The approximate expenditure, choice of hospitals and tourist destinations, and duration of stay, etc., is discussed. After signing consent bonds and agreements, the patient is given recommendation letters for a medical visa, to be procured from the concerned embassy. The patient travels to the destination country, where the medical tourism provider assigns a case executive, who takes care of the patient's accommodation, treatment and any other form of care. Once the treatment is done, the patient can remain in the tourist destination or return home.

International healthcare accreditation

Main article: International healthcare accreditation

International healthcare accreditation is the process of certifying a level of quality for healthcare providers and programs across multiple countries. International healthcare accreditation organizations certify a wide range of healthcare programs such as hospitals, primary care centers, medical transport, and ambulatory care services.[17]

The oldest international accrediting body is Accreditation Canada, formerly known as the Canadian Council on Health Services Accreditation[citation needed], which accredited the Bermuda Hospital Board as soon as 1968. Since then, it has accredited hospitals and health service organizations in ten other countries.

In the United States, the accreditation group Joint Commission International (JCI) has been inspecting and accrediting health care facilities and hospitals outside of the United States since 1999.[citation needed] Many international hospitals today see obtaining international accreditation as a way to attract American patients.[18]

Joint Commission International is a relative of the Joint Commission in the United States. Both are independent private sector not-for-profit organizations that develop nationally and internationally recognized procedures and standards to help improve patient care and safety. They work with hospitals to help them meet Joint Commission standards for patient care and then accredit those hospitals meeting the standards.[19]

QHA Trent Accreditation, based in the UK, is an active accreditation scheme.[20] Prior to that, the Trent International Accreditation Scheme was a key player.

The different international healthcare accreditation schemes vary in quality, size, cost, intent and the skill and intensity of their marketing. They also vary in terms of cost to hospitals and healthcare institutions making use of them.[21] A forecast by Deloitte Consulting regarding medical tourism published in August 2008 noted the value of accreditation in ensuring quality of healthcare and specifically mentioned JCI, ISQUA and Trent.

Increasingly, some hospitals are looking towards dual international accreditation, perhaps having both JCI to cover potential US clientele, Trent for potential British and European clientele and Accreditation Canada. As a result of competition between clinics for American medical tourists, there have been initiatives to rank hospitals based on patient-reported metrics.[22]

Other organizations providing contributions to quality practices include:
The United Kingdom Accreditation Forum (UKAF) is an established network of accreditation organisations with the intention of sharing experience good practice and new ideas around the methodology for accreditation programmes, covering issues such as developing healthcare quality standards, implementation of standards within healthcare organisations, assessment by peer review and exploration of the peer review techniques to include the recruitment, training, monitoring and evaluation of peer reviewers and the mechanisms for awards of accredited status to organisations.[23]

Organizations and Associations

The goal of such associations is often to raise awareness of medical tourism in the hopes of expanding the industry.

Medical Tourism Association (MTA) is a 501(c) non-profit trade association. It is made up of international hospitals, healthcare providers, medical travel facilitators, insurance companies, and other affiliates.[24]

HealthCare Tourism International (HTI) is a 501(c) non-profit organization that is complementary to the Joint Commission International accreditation group. Health care organizations can apply for self-certification or accreditation on the HTI website.[25]

Risks

Medical tourism carries some risks that locally-provided medical care does not. Some countries, such as India, Malaysia, or Thailand have very different infectious disease-related epidemiology to Europe and North America. Exposure to diseases without having built up natural immunity can be a hazard for weakened individuals, specifically with respect to gastrointestinal diseases (e.g. Hepatitis A, amoebic dysentery, paratyphoid) which could weaken progress, mosquito-transmitted diseases, influenza, and tuberculosis. However, because in poor tropical nations diseases run the gamut, doctors seem to be more open to the possibility of considering any infectious disease, including HIV, TB, and typhoid, while there are cases in the West where patients were consistently misdiagnosed for years because such diseases are perceived to be "rare" in the West.[26]

The quality of post-operative care can also vary dramatically, depending on the hospital and country, and may be different from US or European standards. However, JCI and Trent fulfill the role of accreditation by assessing the standards in the healthcare in the countries like India, China and Thailand. Also, traveling long distances soon after surgery can increase the risk of complications. Long flights and decreased mobility in a cramped airline cabin are a known risk factor for developing blood clots in the legs such as venous thrombosis or pulmonary embolus economy class syndrome. Other vacation activities can be problematic as well — for example, scars may become darker and more noticeable if they sunburn while healing.[27] To minimise these problems, medical tourism patients often combine their medical trips with vacation time set aside for rest and recovery in the destination country.

Also, health facilities treating medical tourists may lack an adequate complaints policy to deal appropriately and fairly with complaints made by dissatisfied patients.[28]

Differences in healthcare provider standards around the world have been recognised by the World Health Organization, and in 2004 it launched the World Alliance for Patient Safety. This body assists hospitals and government around the world in setting patient safety policy and practices that can become particularly relevant when providing medical tourism services.[29]

Finally, after returning home, a patient will have limited contact with his or her surgeon. This means that it will be difficult to deal with any complications that may arise later such as a delayed infection.

However, balancing potential risks is the fact that in some foreign hospitals most or all nurses are registered nurses, as opposed to the nurses aides or other less qualified personnel which are commonly used in American hospitals. Understaffing and the use of overworked and fatigued nursing staff, which is common in American hospitals, may not be as prevalent in some foreign hospitals.

Legal issues

Receiving medical care abroad may subject medical tourists to unfamiliar legal issues.[30] The limited nature of litigation in various countries is one reason for the lower cost of care overseas. While some countries currently presenting themselves as attractive medical tourism destinations provide some form of legal remedies for medical malpractice, these legal avenues may be unappealing to the medical tourist. Should problems arise, patients might not be covered by adequate personal insurance or might be unable to seek compensation via malpractice lawsuits. Hospitals and/or doctors in some countries may be unable to pay the financial damages awarded by a court to a patient who has sued them, owing to the hospital and/or the doctor not possessing appropriate insurance cover and/or medical indemnity.[31]

Ethical issues

There can be major ethical issues around medical tourism.[30] For example, the illegal purchase of organs and tissues for transplantation had been alleged in countries such as India[32][33] and China[34] prior to 2007. The Declaration of Istanbul distinguishes between ethically problematic "transplant tourism" and "travel for transplantation".[35]

Medical tourism may raise broader ethical issues for the countries in which it is promoted. For example in India, some argue that a "policy of 'medical tourism for the classes and health missions for the masses' will lead to a deepening of the inequities" already embedded in the health care system.[36] In Thailand, in 2008 it was stated that, "Doctors in Thailand have become so busy with foreigners that Thai patients are having trouble getting care".[37] Medical tourism centred on new technologies, such as stem cell treatments, is often criticized on grounds of fraud, blatant lack of scientific rationale and patient safety. However, when pioneering advanced technologies, such as providing 'unproven' therapies to patients outside of regular clinical trials, it is often challenging to differentiate between acceptable medical innovation and unacceptable patient exploitation.[38][39]

Employer-sponsored health care in the US

Some US employers have begun exploring medical travel programs as a way to cut employee health care costs. Such proposals have raised stormy debates between employers and trade unions representing workers, with one union stating that it deplored the "shocking new approach" of offering employees overseas treatment in return for a share of the company's savings. The unions also raise the issues of legal liability should something go wrong, and potential job losses in the US health care industry if treatment is outsourced.[40]

Employers may offer incentives such as paying for air travel and waiving out-of-pocket expenses for care outside of the US. For example, in January 2008, Hannaford Bros., a supermarket chain based in Maine, began paying the entire medical bill for employees to travel to Singapore for hip and knee replacements, including travel for the patient and companion.[41] Medical travel packages can integrate with all types of health insurance, including limited benefit plans,[42] preferred provider organizations and high deductible health plans.

In 2000 Blue Shield of California began the United States' first cross border health plan. Patients in California could travel to one of the three certified hospitals in Mexico for treatment under California Blue Shield.[43] In 2007, a subsidiary of BlueCross BlueShield of South Carolina, Companion Global Healthcare, teamed up with hospitals in Thailand, Singapore, Turkey, Ireland, Costa Rica and India.[44] A 2008 article in Fast Company discusses the globalization of healthcare and describes how various players in the US healthcare market have begun to explore it.[45]

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