Beyond Borders: Traveling Abroad for Medical Care

2014 - 2 April – Patient- and Family-Centered Care
Julie Mayglothling, MD, FACEP, FCCM
An expert explores the medical tourism phenomenon and its implications.
 
With the cost of medical care skyrocketing in the United States, many Americans choose to go abroad for everything from doctor visits to dental care to surgical procedures. Patients Beyond Borders (www.patientsbeyondborders.com) – a leading resource for international medical and health travel – estimates that the market for medical tourism is increasing at an annual rate of 15% to 25%. Patients Beyond Borders defines a medical tourist as “anyone who travels across international borders for the purpose of receiving medical care. We do not count in-country expatriates, tourists in need of emergency medical care, companions accompanying medical travelers, or multiple patient episodes that occur over the course of one trip.” Patients Beyond Borders estimates that around 11 million people travel globally for healthcare and that about 1.2 million are Americans. After their care abroad, some of these patients may end up in the critical care unit with unique needs and backgrounds. Intensive and emergency care professionals should be aware of challenges posed by this patient population.

Given the rise of medical tourism, it is reasonable to assume that many practitioners will encounter patients who have traveled abroad for care. As a result, the initial visit, particularly for urgent or emergent care, should include a specific query regarding any prior care that was received outside of the home country. Clearly, the time-honored travel questions practitioners ask must cover more than vacation travel because medical management, periprocedural preparation, conduct, and aftercare may vary significantly from that commonly provided in the country of origin. When treatments have gone awry, patients may require care in the intensive care unit. Accordingly, clinicians who provide primary or critical care benefit by being well informed regarding the risks, benefits and available resources for practitioners and medical travelers. Such knowledge helps support excellence in patient care and enables patients to make informed decisions both before and after travel as medical tourists.
 
Why Medical Tourism?

American medical tourists are generally traveling to a less-developed country for lower-cost care, and the cost savings can be significant, according to the U.S. Centers for Disease Control and Prevention. Patients Beyond Borders projects the average range of savings, based on the U.S. dollar, for the most popular destinations as:

• Brazil: 20% to 30%
• Costa Rica: 45% to 65%
• India: 65% to 90%
• Korea: 30% to 45%
• Malaysia: 65% to 80%
• Mexico: 40% to 65%
• Singapore: 25% to 40%
• South Korea: 30% to 45%
• Taiwan: 40% to 55%
• Thailand: 50% to 75%
• Turkey: 50% to 65%
 
 The top specialties for medical travelers are:

• Cosmetic surgery
• Dentistry (general, restorative, cosmetic)
• Cardiovascular (angioplasty, coronary artery bypass grafting, transplantation)
• Orthopedics (joint and spine, sports medicine)
• Cancer (often high-acuity/complex/advanced stage; care frequently declined at home)
• Reproductive (fertility, women’s health)
• Weight loss (adjustable gastric banding surgery, gastric bypass)
• Scans, tests, health screenings, and second opinions
 
Concerns for Patients and Healthcare Providers

Although medical tourism has not increased as rapidly as predicted – in part because insurers and governments have not invested as much as expected in pursuing this option on a large scale – it is still a concern for U.S. healthcare providers and patients. Given the number of countries patients are patronizing, coupled with the wide variation in quality of care, patients may find it difficult to truly evaluate the care delivered or anticipated. Among patient risks are: miscommunication due to a language barrier, unscreened blood supply, counterfeit medications, increased risk of venous thromboembolism during air transit after surgery, and lack of timely follow-up care upon return to the home country. Likewise, as medical providers, we risk being called to care for patients whose medical records may be in another language, unobtainable, or nonexistent.

In response to this growing industry, The Joint Commission, a U.S.-based accreditation organization, launched its international affiliate accreditation agency, Joint Commission International (JCI), in 1999. To be accredited by the JCI, an international hospital must meet the same set of rigorous standards set forth in the United States by The Joint Commission. More than 600 facilities around the world have now been awarded JCI accreditation, and that number is growing by about 20% per year. This is helping patients evaluate facilities and hospitals and be assured that certain standards of care are upheld. In addition, several major medical schools in the United States have established joint overseas initiatives, such as the Harvard Medical School Dubai Center, the Johns Hopkins Singapore International Medical Centre, and the Duke-National University of Singapore. The American insurer, BlueCross/BlueShield, created a subsidiary for medical tourism, Companion Global Healthcare, that connects patients with hospitals around the world.
 
In a 2010 article(1) and in an upcoming book, Patients with Passports: Medical Tourism, Law, and Ethics (Oxford University Press), Harvard Law School Professor I. Glenn Cohen addresses some of medical tourism’s potential legal and ethical issues. One major concern is patients seeking treatments that are illegal in their own countries, such as reproductive technologies or experimental therapies for critically ill children. He also raises the issue of pursuing treatments that are illegal in both home and destination countries, such as the purchase of organs for transplantation. Another potential risk for patients is practitioner accountability and malpractice options for substandard care that results in harm. Depending on the laws of the destination country, patients may be left with devastating complications and no recourse for remediation or financial remuneration or compensation.

Medical tourism is a sizeable industry that is also quite profitable. In an October 16, 2012, interview, Cohen stated, “When I go to medical tourism conferences, I am always surprised at how many people are in marketing. It seems like an industry much more dominated by the business and the marketing people rather than the healthcare people.”(2) Most U.S. patients pursuing medical travel use private, for-profit companies to coordinate their treatment. These companies arrange travel, accommodations, follow-up care, rehabilitation, and even leisure activities. In addition, medical tourism not-for-profit associations provide members with information from webinars, newsletters and conferences, and share experiences and resources with other travelers. Despite the putative educational and informational value, such publications and Web sites are littered with advertisements and links to private companies. Even after accounting for company surcharges, the cost savings realized continue to drive patients to travel for certain kinds of care.
 
References:
 
1.  Cohen IG. Protecting patients with passports: medical tourism and the patient protective-argument (June 9, 2010). Iowa Law Review, Vol. 95, No. 5, 2010; Harvard Public Law Working Paper No. 10-08. http://ssrn.com/abstract=1523701. Accessed April 9, 2014.
2.  Walsh C. The rise of medical tourism.  Harvard Gazette. October 16, 2012. http://news.harvard.edu/gazette/story/2012/10/the-rise-of-medical-tourism. Accessed April 9, 2014.