Medical tourism

Medical tourism

Medical tourism (MT) is defined as patient movement from highly developed nations to less developed areas of the world for medical care by bypassing services offered in their own communities. Medical tourism is different from the traditional model of international medical travel where patients generally journey from less developed nations to major medical centers in highly developed countries for medical treatment that is unavailable in their own communities.[1][2] While the general definition of the MT above covers most of the aspects of the phenomenon, there is no international consensus yet on the name of the phenomenon. MT is often related to globalisation and neo-liberal healthcare policies which in this case considered to undermine the quality and quantity of the services available to middle class in home countries.

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. Individuals with rare genetic disorders may travel to another country where treatment of these conditions is better understood. 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.

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.

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.[4] The avoidance of waiting times is the leading factor for medical tourism from the UK, whereas in the US, the main reason is cheaper prices abroad. In 2009, there were 60,000 patients going for treatment abroad in the UK.[5]

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 costs $300,000 USD in America costs about $91,000 USD in Taiwan.[6] 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.[7] 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.[8] 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.[9]

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".[10]

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.

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, Thailand 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".[11]A specialized subset of medical tourism is reproductive tourism and reproductive outsourcing,[12] 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.[13]

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 physicians 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.[14]

 

The oldest international accrediting body is Accreditation Canada, formerly known as the Canadian Council on Health Services Accreditation,[15] 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.[16]

 

Joint Commission International is a relative of the Joint Commission in the United States. Both are US-style 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.[17]

 

QHA Trent Accreditation, based in the UK, is an active independent holistic accreditation scheme.[18][19]

 

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.[20] 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, QHA 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.[21]

 

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.[22]

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 and expose the patient to 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.[23]

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. Also, traveling long distances soon after surgery can increase the risk of complications. Long flights and decreased mobility associated with window seats can predispose one towards developing deep vein thrombosis and potentially a pulmonary embolism.[24] Other vacation activities can be problematic as well — for example, scars may become darker and more noticeable if they sunburn while healing.[25]

 

Also, health facilities treating medical tourists may lack an adequate complaints policy to deal appropriately and fairly with complaints made by dissatisfied patients.[26]

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.[27]

If there are complications, the patient may need to stay in the foreign country for longer than planned or if they have returned home, will not have easy access for follow up care.[28]

Legal issues

Receiving medical care abroad may subject medical tourists to unfamiliar legal issues.[29] 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.[30]

Ethical issues

here can be major ethical issues around medical tourism.[29] For example, the illegal purchase of organs and tissues for transplantation had been alleged in countries such as India[31][32] and China[33] prior to 2007. The Declaration of Istanbul distinguishes between ethically problematic "transplant tourism" and "travel for transplantation".[34]

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.[35] 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".[36] 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.

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.[39]

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.[40] Medical travel packages can integrate with all types of health insurance, including limited benefit plans,[41] 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.[42] 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.[43] 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.

Subfields

[edit]

Dental

Main article: Dental tourism

 

Dental tourism involves individuals seeking dental care outside of their local healthcare systems. Over 60,000 UK patients have already travelled abroad in 2011 with majority of them choosing dental treatments across Hungary, Poland and Turkey.[5] Slovakia, Czech Republic & Romania are another rising destinations for dental tourism. The number one reason for travelling abroad was the price difference, patients on average saved 50%-70% of the treatment costs.

However, for patients with small amount of dental work or other medical difficulties such as heart, blood, respiratory or mobility problems dental tourism might not be the best option given the required travelling costs & risks associated with flying. If patients are in need of a major dental restoration or reconstruction involving dental implants, a bone graft or a full smile makeover, then there is a huge potential to make great savings and have better access to excellent dental doctors and top-level facilities and dental tourism can be great mean to achieve these goals.

Fertility

Main article: Fertility tourism

Fertility tourism is the practice of traveling to another country for fertility treatments.[45] The main reasons for fertility tourism are legal regulation of the sought procedure in the home country, or lower price. In-vitro fertilization, donor insemination and surrogacy are major procedures involved.

Destinations

Africa and the Middle East

Israel

See also: Medical tourism in Israel

Israel is emerging as a popular destination for medical tourists.[46] In 2006, 15,000 foreigners travelled to the country for medical procedures, bringing in $40 million of revenue.

Medical tourists choose Israel for several reasons. Some come from European nations such as Romania where certain procedures are not available.

Other medical tourists come to Israel to visit the Dead Sea, a world-famous therapeutic resort.[46] The Israel Ministry of Tourism and several professional medical services providers have set out to generate awareness of Israel's medical capabilities.[47]

Iran

Iran is also among the 12 countries with biological medicines technology and can serve as a health tourism center.[48] 30,000 people come to Iran each year to receive medical treatment (2012).[49]

Jordan

Jordan is an emerging medical tourism destination, with related revenues exceeding one billion dollars in 2007.[50] More than 250,000 patients from other countries sought treatment in Jordan that year. This included an estimated 45,000 Iraqis and approximately 25,000 patients each from Palestine and Sudan. An estimated 1,800 US citizens, 1,200 UK citizens, and 400 Canadians also sought treatment in Jordan that year. Treatment costs can be as low as 25 percent of costs in the US.[50] The kingdom was rated as number one in the region and fifth in the world as a medical tourism hub in a study by the World Bank.[50]

United Arab Emirates

Hospitals in Dubai and other emirates have expressed an intent to develop in medical tourism.[51] Some have American-sourced international healthcare accreditation, while others are looking towards the UK, Australia and Canada for accreditation services. For example, QHA Trent has now accredited several hospitals in the UAE.

South Africa

South Africa is the first country in Africa to emerge as a medical tourism destination.[52] It offers medical and dental care.[53][non-primary source needed]

The Americas

Countries in the Americas that are treating foreign patients include Argentina, Bolivia, Brazil, Colombia, Costa Rica, Cuba, Dominican Republic, Guatemala, Mexico, Panama, Peru and Uruguay.

Brazil

Brazil has long been known as a destination for cosmetic surgery. For non-cosmetic procedures, Brazil is only now entering the global market. However, Albert Einstein Jewish Hospital in São Paulo was the first JCI-accredited facility outside of the US,[54] and more than a dozen Brazilian medical facilities have since been similarly accredited.[55] Brazil requires visas for US citizens based on a reciprocal arrangement since Brazilians are required to obtain a visa to visit the US. Unlike in the U.S and other countries where medical procedures are simply done in an office, Plastic surgery in Brazil is done only in specialized clinics or hospitals.[56] [57]

Canada

Canada has entered the medical tourism field. In comparison to US health costs, medical tourism patients can save 30 to 60 percent on health costs in Canada.[58]

Colombia

Colombia is most likely the most underestimated destination for Global Healthcare in the Americas. Struggling with security and drug-related issues more than 15 years ago, Colombia is today one of the most thriving economies in South America and safe for tourists.[59] Colombia's major cities like Bogota, Medellin, Cali and Cartagena are already receiving more than 1.45 million tourist each year and the numbers are increasing.[60] Global Healthcare has been identified as one of the main drivers for economic growth in the medical sector. Patients from the Caribbean already know Colombia as a first class destination for medical procedures and cosmetic treatments. Now hospitals and facilitators are beginning to successfully convince also US-Americans of the quality of medical services provided in the country. An independent platform to compare the quality and prices of medical and cosmetic services is being supported by the government's export agency and regional initiatives.[61] Colombia is overcoming its stigma and becoming a major player in Global Healthcare, serving needs of patients all over the Americas.

United States

A McKinsey and Co. report from 2008 found that between 60,000 to 85,000 medical tourists were traveling to the United States for the purpose of receiving in-patient medical care.[77] The same McKinsey study estimated that 750,000 American medical tourists traveled from the United States to other countries in 2007 (up from 500,000 in 2006).[78] The availability of advanced medical technology and sophisticated training of physicians are cited as driving motivators for growth in foreigners traveling to the U.S. for medical care,[77] whereas the low costs for hospital stays and major/complex procedures at Western-accredited medical facilities abroad are cited as major motivators for American travelers.[78] Also, the decline in value of the U.S. dollar is offering additional incentive for foreign travel to the U.S., although cost differences between the US and many locations in Asia far outweigh[clarification needed] any currency fluctuations.

Several major medical centers and teaching hospitals offer international patient centers that cater to patients from foreign countries who seek medical treatment in the U.S.[79] Many of these organizations offer service coordinators to assist international patients with arrangements for medical care, accommodations, finances and transportation including air ambulance services.

Many locations in the US that offer medical care comparable in price to foreign medical facilities are not Joint Commission Accredited.