June 4, 2007

Patients without Borders: The Emergence of Medical Tourism

Most Health Letter readers are familiar with the extraordinary international organization of doctors, Doctors Without Borders (Médécins Sans Frontières), that transcends and travels beyond national boundaries to bring better health conditions and better health care to those in need. But a rapidly emerging phenomenon is medical tourism, a sort of “patients without borders”, reflecting different kinds of need.

Part 1

Bathing suit, sun block, x-rays, medical records… these may all be priorities in packing for travel to a far-flung location. In recent months, the media have picked up on a growing trend: medical tourism, or travel with the express purpose of obtaining health services abroad. For this country, the trend is not new, although the direction of patient flow certainly is. The United States, with its large pharmaceutical and medical device industries and high-tech hospitals, has traditionally been a destination for patients, primarily those affluent enough to pay out-of-pocket or those who have generous insurance coverage that extends beyond their countries of origin. But recent years have seen a flow in the opposite direction, with large numbers of American patients traveling abroad in search of less expensive and often more luxurious health care.

For a patient in, say, New York or Washington, who may be under the care of an Indian physician and a Jamaican or Filipino nurse, going abroad for medical services may not seem dissimilar to getting care at home. And the promise of comparable services at lower cost, with some exotic travel thrown in, is often tempting. As a result, patients are increasingly looking for newer horizons in medical care, including elective surgery and long-term care. Some countries such as India, Brazil, the Philippines, and Thailand are actively capitalizing on the trend, offering health care/resort packages that promise the best of medicine with the attractions of tourism…. all for a fraction of what equivalent health services would be in the US. In a two-part series, Health Letter will examine some of the implications of this trend. Here, we will look into what this means for the countries involved on either side of the exchange. In the second part of the series, we will focus on what the individual consumer should know when contemplating going abroad for the main purpose of getting health care.

A segmented market

There has always been a market for celebrities or the wealthy seeking care outside the US, usually for reasons of privacy. It is not only Angelina Jolie, who gave birth in Namibia, who travels for health care. Other medical tourists undergo cosmetic surgery or other ‘delicate’ procedures where they do not have to explain their temporary absences. Plastic surgeons in Europe and Israel often attract international clients, and some hospitals have built reputations based on both their discretion and their results.

Beyond these special cases, there are others who go abroad for routine services. As has been well documented, many Americans travel to Canada to buy prescription drugs, and border drugstores cater to this growing clientele. Along the southern border, poor Mexicans can buy less expensive insurance from US insurers, benefiting from services on both sides of the border. They often go to Mexico for routine care, while relying on US services for serious problems.  Retired Americans who have second homes in Mexico, or who live in South Texas and Arizona, similarly avail themselves of services in Mexico. The growing market for these services has attracted both providers and more patients, with some border towns specializing in certain types of services and drawing from a broad catchment area. Indeed, a recent Time article describes the towns of Nuevo Progreso and Los Algodones in Northern Mexico as “dental oases” attracting chartered flights full of patients from Minnesota and California in search of more affordable dental care.  

In the past decade, a growing number of US patients have turned to other countries for surgical and other care. Trade in health care services therefore now includes a number of countries promising “first-class services at third-world prices.” These, which include countries as diverse as South Africa and Poland, Singapore and Argentina, among others, cater to a population demanding less expensive care (from countries in which care is market-driven) or who want to “jump the queue” (from countries where publicly funded services are universally available, but where there may be unacceptably long waiting lines). Whatever the motivation, medical tourists are on the move and on the rise, and their mere presence has implications for both their home country and their hosts. The examples of India and Thailand shed some light on what is at stake nationally and internationally.

Think locally, market globally

Countries that actively promote medical tourism do so for self-serving reasons. Investing in the medical industry is a way to increase GDP, upgrade services, generate foreign exchange and create a more favorable balance-of-trade situation, and boost tourism. Other more subtle benefits include stemming a brain drain of health professionals and buying international goodwill.

The full impact of these gleaming “islands of medical excellence in a sea of medical neglect,” however, is the subject of intense debate. What does the trend mean for the public’s health? Do benefits accrue to the local population, or are private hospitals benefiting at their expense? Those who advocate for this potential growth industry stress two main points: (1) that the increased revenues provided by medical tourism can be plowed back into health care to benefit the population at large; and (2) that the upgraded facilities catering to foreigners can have a leavening or demonstration effect on health services throughout the system, serving as an example of what is possible in the developing world given existing know-how and additional resources. Both of these arguments assume a favorable ‘trickle down’ effect of improved services. The opposing view is that luxury health care designed for foreigners (or, in the case of India, expatriates) widens the gap between have and have-nots, and that poor countries are being lulled into thinking that they are improving their health services by having impressive high-tech hospitals that serve only the needs of affluent outsiders. The full impact of the trend will most likely vary from one country to another, and its effects are being watched by other countries and global organizations.

The case of Thailand

If there is an apex in the hierarchy of hospital services in Asia, it is Bumrungrad Hospital in Bangkok. Aiming at what John D. Rockefeller Jr. called “catalytic bigness,” this 554-bed facility with a staff of 2,600 has spent the last decade striving to be the biggest and best in its class. It attracts international patients from over 150 different countries and has become a pioneering force in global medical entrepreneurship. In order to establish itself as a brand apart in the health tourism industry, it hired not only experienced doctors but also foreign management expertise. It was also the first hospital in Asia to receive accreditation from the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), an organization that offers its stamp of approval to healthcare organizations that meet certain standards for patient safety and other predetermined criteria. This paved the way for others. At present, it boasts an international medical center catering primarily to foreign patients, who account for 50 percent of their clientele. The hospital staff includes interpreters for 26 languages and a department specifically for Japanese visitors. In 2003, Bumrungrad treated one million patients. In 2005, it treated 55,000 American patients, three-quarters of whom flew directly from the US. A recent financial report for the hospital reveals that the company is increasing its outpatient capacity, exporting its managerial expertise to hospitals in Myanmar and Bangladesh, and aggressively pursuing other opportunities to strengthen its position in Asia. It has also acquired stock in hospitals in the Philippines and Bangladesh, and is providing consulting services throughout the region. In addition, the CEO is quoted as saying that the hospital is looking into opportunities in Malaysia, Vietnam, China, and the Middle East, “where the number of health-conscious middle-class people is growing.”

While Bumrungrad may be unique in its scale and relative endowment, it is emblematic of what may be happening in other private hospitals also vying to attract patients from abroad. Because few patients travel for routine care, medical tourism means emphasizing treatment over prevention, and promoting technology-intensive tertiary services at the expense of primary care. The fact that the private health sector in Bangkok has more gamma knife, CAT scan, and mammogram capacity than all of England is evidence of the distortions that occur in the allocation of resources when these are spent for status symbols rather than to meet local needs.  

The implications of this for the country are being discussed by WHO and its regional offices as well as by the World Bank and other development and international trade organizations. Because technology is more mobile than labor resources, a country such as Thailand can import the former, upgrade the latter, and bolster its comparative advantage vis-à-vis the developed world. But to do so successfully, it has to invest a disproportionate share of finite resources in services for the affluent, thus distorting any redistributive effect of better care. And the presence of well-endowed hospitals tends to prompt an internal brain drain from the public to the private sector, thereby decreasing equity in access to health care for the local population. This siphoning off of health personnel from the public to the private sector is already occurring in Thailand. The effect of these trends thus reinforces a two-tiered health system, with different standards for different economic classes.  

Medical tourism in India

Building on its experience in selling its labor and expertise in information technology on the international market, India is following Thailand in promoting “hi-tech healing” in order to become a global health destination. The country has already established a reputation in cardiac care, cosmetic surgery, joint replacement, and dentistry, and is actively working to expand into other areas that may attract well-heeled foreigners and the 12 million Indian expatriates who can combine regular visits to India with non-emergency medical procedures. India also hopes to capitalize on its traditions of Ayurvedic and other non-allopathic treatments, which might constitute a special niche and attract another clientele.

But positioning itself in the global medical market means a lot of changes, and most of those require government subsidies. The ingredients for success include inducing the government to support the enterprise through incentives or tax breaks, adopting international accreditation standards, negotiating with insurers to facilitate coverage for overseas patients, and aggressively selling India as a desirable medical Mecca. The possibility of earning $1 billion from medical tourism by 2012 looms large. India’s National Health Policy adopted in 2002 therefore explicitly seeks to “encourage the supply of services to patients of foreign origin on payment;” such payment is treated as ‘deemed exports,’ which makes them eligible for all fiscal incentives extended to export earnings. As in the case of Thailand, the redistributive effect of these policies favors the private sector at the expense of the public. Government spending on public health infrastructure is shrinking; data released in 2004 show that nearly 82 percent of all health expenditures in India is private.

This has raised the issue of equity in access to care. In the words of the dean of the King Edward Memorial Hospital in Mumbai, “The need to benefit Indian patients is the main goal, and medical tourism cannot be at their cost.” And another critic has attacked the current policies as undermining equity in both India and the countries of origin:

Medical tourism…reinforces the medicalized view of health care. By promoting the notion that medical services can be bought off the shelf from the lowest priced provider anywhere in the globe, it also takes away the pressure from the government to provide comprehensive health care to all its citizens… The services are ‘cost effective’ for those who can pay and …come from countries where medical care costs are exorbitant because of the failure of the government to provide affordable medical care.

In short

US consumers who view medical tourism as a relatively harmless international means to share the wealth should rethink their position. There are compelling reasons not to encourage the outsourcing of health services. The international market in health care can have adverse effects on the host country as well as on the exporting one. Whatever the lures of the “scalpel safari” or the “rainforest-and-rhinoplasty” package, the undermining of fair shares in health may be the unkindest cut of all.

Part 2

A growing number of U.S. patients are turning to other countries for surgical and other care. The lure of “first-class services at third-world prices,” as tantalizingly portrayed in the electronic and other media, is attracting those who want to combine their care with a vacation, are seeking alternative therapies, or are simply enticed by the lower prices of most procedures. In the previous article, we provided a summary of some of the international and local implications of the trends for the countries involved. Here, we will present some of the trade-offs the U.S. consumer is making when opting for medical tourism, and some of the issues that should inform this decision.  

How good is the care?

For Americans going abroad, the possibility of trading off quality care for affordability may be of vital importance. And the choice consumers face between “suffering with a health problem or facing significant damage to their finances” may not be easy.

The short answer to the question concerning quality is: it depends. As with health services in the United States, the quality of the product can vary widely, and patients are often not in a position to judge what they are getting. In the absence of standards, the obvious trappings of care — physical facilities, size and cleanliness of rooms, availability of staff, physician attentiveness — often take precedence over medical skill and accountability. It is therefore not surprising that hospitals seeking to attract foreign patients have taken pains to provide the amenities that ensure patient approval. Many have therefore invested an inordinate amount of resources to create posh facilities combining high-technology medicine with resort attractions.

In addition, some hospitals designed for a foreign clientele have adopted Western standards of care, and sought and obtained accreditation from the international arm of the Joint Commission for the Accreditation of Healthcare Organizations. They also capitalize on the fact that some of their physicians were trained in the West. And, because they are in the hospitality business, they tend to have a high staff-to-patient ratio and stress gracious care.  

What does this mean for the U.S. consumer?

American medical consumers who are able to travel see the expanding global market as another option enabling them to get care at affordable prices. Because pay scales are lower and service volumes higher in a number of developing countries, their medical “products” may be significantly cheaper. In some cases, surgical procedures may cost a fifth and even a tenth of what they would cost in the United States. With few or no restrictions concerning length of stay, patients may appreciate relief from drive-by surgeries and difficult convalescences at home. And the promise of “peaceful relaxation in complete anonymity” may appeal to those who want to avoid prying eyes and uncomfortable questions. For the more adventurous, the possibility of exploring another culture and environment may be seen as a bonus. Moreover, the Internet has greatly eased the process of getting information about far-flung hospitals, bridging distances and making the exotic deceptively familiar. Some businesses specialize in orchestrating both the travel and medical arrangements, easing the process by providing Destination Program Managers (DPM) to help the patient navigate the new system upon arrival in the new setting. “All you really need is an air ticket!” pledges one enterprising company.

Nevertheless, there are a number of factors to which the potential consumer should be alert. While seemingly ancillary to medical care, they can greatly influence, if not determine, the efficacy of treatment and the success of the experience.  

1. Travel may be contraindicated. Unless the patient is getting an elective procedure (which may very well be unneeded and risky), he or she may have a condition that is exacerbated by airplane travel. A 10-hour plane trip can be stressful, and being strapped in a seat confined to a small space, with limited mobility, for a long time may trigger deep-vein thrombosis (DVT), more commonly called “coach class syndrome.” This rare but possibly lethal condition is a risk of long-distance travel. The combination of immobility, dehydration, and seat pressure on veins at or below the knees increase the risk of blot clot formation and hence of a pulmonary embolism. Undiagnosed in 80 percent of cases, DVT is nevertheless  associated with a wide range of risk factors, including varicose veins, pregnancy, recent surgery, autoimmune disorders, Type A blood, cancer/chemotherapy, clotting disorder, congestive heart failure, elevated cholesterol, inflammatory bowel disease, and elevated platelet counts. As a result, many potential medical travelers may be unwittingly placing themselves at risk and possibly worsening the condition for which they are seeking care in the first place.  
2. Insurance coverage may be spotty. While is it mostly the uninsured who seek health services outside the United States, some insured individuals may also opt to undergo elective surgery abroad. In the latter case, it is important for consumers to verify beforehand that they will be covered or reimbursed for expenses incurred abroad. Each insurance plan has specific requirements governing coverage. Aetna, for example, covers routine care outside the U.S., but only for certain beneficiaries: those not in closed-panel HMOs. In most cases, insurers exclude cosmetic and other elective surgery. In addition, even when care is covered by insurance, there may be other hurdles to coverage. For example, pre-certification may be required. In addition, some insurers cover complicated transplant procedures only if these are performed in specific medical centers that meet established quality standards and other criteria for care. As incentives for patients to choose these “centers of excellence,” some insurers may offer travel and lodging reimbursement. Patients should read the small print and get information in writing before making a final decision concerning where to get care.  
3. Continuity of care can be compromised. In-hospital service represents a small part of the continuum of care. Longitudinal responsibility for a patient’s care fosters accountability and reciprocity on the part of both patients and providers. Even if the patient remains in the country following treatment, long-term follow-up may be difficult. While proximity is neither necessary nor sufficient for continuity of care, it certainly facilitates it. Patients traveling for a procedure should take their medical records, including test results and x-rays. In addition, they should inform their providers at home of their plans in order to ensure easy access to medical data and consultation.
4. Problems of communication may arise. Many medical errors are the result of poor communication. Misunderstandings and gaps in information often occur when a provider speaking medical jargon is face-to-face with a nervous patient. Adding linguistic, cultural, and class barriers to the mix further complicates the situation. Additionally, religious and gender nuances and taboos may increase the probability of missed cues or misconstrued messages.  
5. An adequate support network will most likely be missing. Most patients require help during convalescence. In the event of a prolonged recovery, the patient/tourist may feel stranded with limited help. There is no “mustering the troops” when the patient is alone or has a single companion. There are occasions when the familiar is comforting and broader resources may be needed. Illness can be isolating, and a foreign environment can only make a difficult situation more onerous.  
6. “Alternative” treatments may not be the right alternative. Some countries attract patients seeking treatments that are routinely performed elsewhere but are not approved in the United States (e.g., robot-assisted joint replacement). Whatever the deficiencies of the current U.S. regulatory systems, they are designed to limit procedures to those that meet standards of safety and efficacy. More likely than not, there are valid reasons for not approving certain therapies.  
7. “Natural” does not mean “safe.” Most toxic substances are found in nature; that does not make them any less dangerous. Patients equating “natural” with “harmless” run the risk of taking products that may have intrinsic adverse effects or cause bad reactions when taken with other drugs and medications. Moreover, even some seemingly innocuous products may be combined with other ingredients that are potentially toxic. One study of Ayurvedic medications published in 2004 found that, of 70 over-the-counter remedies, 14 (20 percent) contained mercury, lead, or arsenic at levels that could be harmful.  
8. Travel ‘frills’ can eclipse medical care. Patients are well-advised to separate their medical requirements from other aspects of the health travel “package.” If you want cosmetic surgery and are convinced that Argentina is the best place for you, your decision should not be contingent on whether or not the package includes the services of “a personal assistant who will help direct you to …Señor Tango, one of the hottest tango halls in Buenos Aires.”
9. Environmental conditions may not be equal to those of more developed countries. Even if the hospital is impeccable, quality of air and water, noise, and sanitary conditions outside the premises may affect the salubriousness of the environment. Similarly, a blood transfusion can be either a life-saver or a major threat, depending on how the blood supply is screened and managed. There are a number of blood-borne diseases, and many countries lack adequate means for their surveillance and prevention. According to a World Health Organization study, 11 percent to 21 percent of cities surveyed had inadequate screening of blood donations for the infectious agents associated with malaria, HIV, and hepatitis.
10. The “rules of the game” may be quite different. The Centers for Disease Control warns that systems outside the United States may operate differently from those in the U.S. and are not subject to the same rules and regulations. Procedures regarding informed consent, advanced directives, and guardianship, for example, may not be in place. Similarly, hospitals and other health care facilities may maintain discriminatory prices that would not be acceptable in the United States. For example, one company in the health travel business advises potential clients that the charge for a particular surgical procedure may be 30 percent more than the regular rate if the patient is HIV positive.  
11. There may be no legal recourse if needed. In the event of an adverse effect, resorting to a legal process may be difficult or simply not available. Some countries have malpractice laws that limit damage awards, thereby protecting physicians and hospitals from litigation.  

Summing up

U.S. consumers may be well advised to separate their medical needs from their vacations. The lower cost of care abroad, however important a motivator, has to be weighed against other intangibles that can make the difference between success and failure in health outcomes.