Medical tourism

Medical tourism is a form of health tourism commonly referring to the travel of people to another country for the purpose of obtaining medical treatment in that country. Traditionally, people would travel from less-developed countries to major medical centers in highly developed countries for medical treatment that was unavailable in their own communities; the recent trend is for people to travel from developed countries to third-world countries for medical treatments because of cost consideration, though the traditional pattern still continues. Another reason for travel for medical treatment is that some treatments may not be legal in the home country, such as some fertility procedures.

Some people travel to obtain medical surgeries or other treatments. Some people go abroad for dental tourism or fertility tourism. People 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, is available.

Medical tourists are subject to a variety of risks, which may include deep vein thrombosis, tuberculosis, amoebic dysentery, paratyphoid, poor post-operative care, and others.

History

The first recorded instance of people travelling to obtain medical treatment 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. This territory was the sanctuary of the healing god Asklepios.

Spa towns and sanitariums may be considered an early form of medical tourism. In 18th-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. 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.

Many surgery procedures performed in medical tourism destinations cost a fraction of the price they do in other countries. For example, a liver transplant that costs US$300,000 in America costs about 91,000 USD in Taiwan. A large draw to medical travel is convenience and speed. Countries that operate public health-care systems often have long wait times for certain operations. 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. 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.

In First World countries such as 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 1.5 million 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.

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

Additionally, some patients in some First World countries are finding that insurance either does not cover orthopedic surgery (such as knee or hip replacement) or limits the choice of the facility, surgeon, or prosthetics to be used.

Popular medical travel worldwide destinations include: Costa Rica, Ecuador, India, Israel, Malaysia, Mexico, Singapore, South Korea, Taiwan, Thailand, Turkey, United States.

Popular destinations for cosmetic surgery include: Argentina, Bolivia, Brazil, Colombia, Costa Rica, Cuba, Ecuador, Mexico, Turkey, Thailand and Ukraine. 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. Other destination countries include Belgium, Poland, Slovakia, Ukraine and South Africa.

Some people travel for assisted pregnancy, such as in-vitro fertilization, or surrogacy, or freezing embryos for retro-production.

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 which unite potential medical tourists with provider hospitals and other organisations. Companies that focus on medical value travel typically provide nurse case managers to assist patients with pre- and post-travel medical issues. They may also help provide resources for follow-up care upon the patient's return.

Circumvention tourism is also an area of medical tourism that has grown. Circumvention tourism is travel in order to access medical services that are legal in the destination country but illegal in the home country. This can include travel for fertility treatments that aren’t yet approved in the home country, abortion, and doctor-assisted suicide. Abortion tourism can be found most commonly in Europe, where travel between countries is relatively simple. Ireland and Poland, two European countries with highly restrictive abortion laws, have the highest rates of circumvention tourism. In Poland especially, it is estimated that each year nearly 7,000 women travel to the UK, where abortion services are free through the National Health Service. There are also efforts being made by independent organizations and doctors, such as with Women on Waves, to help women circumvent draconian laws in order to access medical services. With Women on Waves, the organization uses a mobile clinic aboard a ship to provide medical abortions in international waters, where the law of the country whose flag is flown applies.

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.

The oldest international accrediting body is Accreditation Canada, formerly known as the Canadian Council on Health Services Accreditation, 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) was formed in 1994 to provide international clients education and consulting services. Many international hospitals today see obtaining international accreditation as a way to attract American patients.

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.

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.

Increasingly, some hospitals are looking towards dual international accreditation, perhaps having both JCI to cover potential US 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.

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.

Risks

Medical tourism carries some risks that locally provided medical care does not.

Some countries, such as South Africa, 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.

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. Other vacation activities can be problematic as well — for example, scars may become darker and more noticeable if they sunburn while healing.

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

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.

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.

Legal issues

Receiving medical care abroad may subject medical tourists to unfamiliar legal issues. 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. Issues can also arise for patients who seek out services that are illegal in their home country. In this case, some countries have the jurisdiction to prosecute their citizen once they have returned home, or in extreme cases extraterritorially arrest and prosecute. In Ireland, especially, in the 1980s-90s there were cases of young rape victims who were banned from traveling to Europe to get legal abortions. Ultimately, Ireland’s Supreme Court overturned the ban; they and many other countries have since created “right to travel” amendments.

Ethical issues

There can be major ethical issues around medical tourism. For example, the illegal purchase of organs and tissues for transplantation had been methodically documented and studied in countries such as India, China, Colombia and the Philippines. The Declaration of Istanbul distinguishes between ethically problematic "transplant tourism" and "travel for transplantation".

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. 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". Medical tourism centered 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.

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. Medical travel packages can integrate with all types of health insurance, including limited benefit plans, 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. 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. 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.

Destinations

Africa and the Middle East

Jordan

Jordan through their Private Hospitals Association, managed to attract 250,000 international patients accompanied by more than 500,000 companions in 2012, with a total revenues exceeding 1B US$. Jordan won the Medical Destination of the year award in 2014 in the IMTJ Medical Travel Awards.

Israel

See also: Medical tourism in Israel

Israel is a popular destination for medical tourism. In 2010, Israel treated 30,000 medical tourists, mostly from the former Soviet Union. There are reports that these medical tourists obtain preferential treatment, to the detriment of local patients. Some people come to Israel to visit health resorts at the Dead Sea, and on Lake Kinneret.

Iran

In 2012, 30,000 people came to Iran to receive medical treatment. In 2015, It is estimated that between 150,000 to 200,000 health tourists come to Iran annually, and it is expected to rise to 500,000 a year.

South Africa

South Africa is the first country in Africa to emerge as a medical tourism destination. It offers medical and dental care.

Americas

Brazil

In Brazil, Albert Einstein Hospital in São Paulo was the first JCI-accredited facility outside of the US, and more than a dozen Brazilian medical facilities have since been similarly accredited. Brazil requires visas for US citizens based on a reciprocal arrangement since Brazilians are required to obtain a visa to visit the US.

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.

Costa Rica

In Costa Rica, there are two Joint Commission International accredited (JCI) Hospitals. Both are in San Jose, Costa Rica. When the World Health Organization (WHO) ranked the world’s health systems in the year 2000, Costa Rica was ranked as no. 36, which was higher than the U.S., and together with Dominica it dominated the list amongst the Central American countries.

The Council for International Promotion of Costa Rica Medicine - PROMED (www.promedcostarica.org) is the official agency regulating the quality and promoting the country as medical tourism destination.

The Deloitte Center for Health Solutions reported a cost savings average of between 30-70% of US prices.

Cayman Islands

Main article: Health City Cayman Islands

Cuba

Main article: Health care in Cuba § Health tourism and pharmaceutics

Ecuador

Ecuador is becoming more recognized as a Medical Tourism destination and a top retirement destination worldwide. Ecuador has been declared by International Living Magazine, "No. 1 out of the 22 best countries on its Annual Retirement Index for five years running." The World Health Organization (WHO) ranked Ecuador as the 6th most improved healthcare system in the world.

Mexico

US doctors point out that the Mexican legal system makes it almost impossible to sue Mexican doctors for malpractice.

Some clinics may also offer alternative medicine therapies that have been proven ineffective or are banned in the United States. The Mexican government has shut down some of these in recent times, in response to controversial cases like that of Coretta Scott King.

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. 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). 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, 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. Also, the decline in value of the U.S. dollar between 2007 and 2013 used to offer additional incentives for foreign travel to the U.S., although cost differences between the US and many locations in Asia are larger than 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. 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.

Asia and the Pacific Islands

China

Investigations into organ harvesting have been carried out. Investigative journalist Ethan Gutmann estimates that the "organs of 65,000 Falun Gong and “two to four thousand” Uyghurs, Tibetans or House Christians were “harvested” in the 2000-2008 period alone".

It is very likely that "each person who travels to China for an organ causes the death of another human". Furthermore, in their announcements to end organ harvesting from prisoners, China only speaks of executed prisoners, but has not acknowledged the organ procurement from non-consenting prisoners of conscience. State-sanctioned organ harvesting continues to this day, according to Doctors Against Forced Organ Harvesting representative Dr. Chen.

Hong Kong

All 12 of Hong Kong's private hospitals have been surveyed and accredited by the UK's Trent Accreditation Scheme since early 2001.

India

Main article: Medical tourism in India

Medical tourism is a growing sector in India. India is becoming the 2nd medical tourism destination after Thailand. India’s medical tourism sector is expected to experience an annual growth rate of 30%, making it a $2 billion industry by 2015. As medical treatment costs in the developed world balloon - with the United States leading the way - more and more Westerners are finding the prospect of international travel for medical care increasingly appealing. An estimated 150,000 of these travel to India for low-priced healthcare procedures every year. Cosmetic surgery, bariatric surgery, knee cap replacements, liver transplants, and cancer treatments are some of the most sought out medical tourism procedures opted by foreigners. Some of the leading hospitals for medical tourism are Apollo Hospitals, Global Hospitals, Bombay Hospital, Hinduja Hospital, Hiranandani Hospital, Akruti Institute of Plastic and Cosmetic Surgery, Columbia Asia, and Fortis Health Care.

Malaysia

See also: Medical tourism in Malaysia

New Zealand

In 2008, it was estimated that on average New Zealand’s surgical costs are around 15 to 20% the cost of the same surgical procedure in the USA.

Pakistan

Main article: Medical tourism in Pakistan

Singapore

Singapore has a dozen hospitals and health centers with JCI accreditation. In 1997 (published 2000), the World Health Organization ranked Singapore's health care system sixth best in the world and the highest ranked system in Asia.

South Korea

The Korea Times reported in a series of articles that Korean hospitals have adopted a discriminatory pricing policy, charging foreigners two to three times more than the full-fee for locals. The paper revealed that the price disparity in medical fees for foreign patients is extremely high, considering that the difference between the lowest and highest fees for the most-sought-after procedures exceeds more than 10 times on average.

It claims the government is overlooking soaring medical fees on foreign patients, who are unprotected from malpractice, discriminatory charging, overpricing and patient privacy rights under the Korean Medical Law. The Korea International Medical Association has been set up to encourage medical tourism.

Thailand

Thailand has 37 JCI-accredited hospitals. In 1994 The Thai Dental Council was established and is the premier governing body of dental practices in Thailand, and has now formulated uniform competency requirements for dental practitioners, thus directly influencing the medical and dental teaching programs. The Ministry of Public Health plays an important role in developing healthcare to promote scientific based education. In addition, the Thai government has placed a more important role in public health programs for its citizens.

Europe

In 2006, it was ruled that under the conditions of the E112 European health scheme, UK health authorities had to pay the bill if one of their patients could establish urgent medical reasons for seeking quicker treatment in another European union country.

Armenia

Armenia has become a destination for those seeking medical tourism options.

Finland

On December 9, 2013 the City of Helsinki decided, that all minors under the age of 18 and all pregnant mothers living in Helsinki without a valid visa or residence permit, are granted the right to the same health care and at the same price as all citizens of the city. This service will be available sometime early year 2014. Volunteer doctors of Global Clinic have tried to help these people, for whom only acute care has been available. This means that the Finnish health care system is open for all people coming outside of the European Union. The service covers special child health care, maternity clinics and specialist medical care etc. practically for free. It is still unclear if this will increase so called health care tourism, because all you have to do is come to Helsinki as a tourist and let the visa expire.

The Global Clinic in Turku offers health care for all undocumented immigrants for free. While the address of the clinic is not widely publicized, the health care officials know where it can be found.

France

British NHS patients have been offered treatment in France to reduce waiting lists for hip, knee and cataract surgery since 2002. France is a popular tourist destination but also ranked the world's leading health care system. This ranking reflects the expertise offered by doctors and surgeons to patients cared for in France. The French National Authority for Health (HAS) issues high-level quality requirements for French health care, with which clinics and hospitals must comply in order to be accredited. European Court of Justice said that National Health Service (England) has to pay back British patients

Germany

Costs for medical treatment in Germany are commonly 50% of those in the USA.

Turkey

The cost of medical treatments in Turkey is quite affordable compared to Western European countries. Therefore, thousands of people each year travel Turkey for their medical treatments. Turkey is especially becoming a hub for hair transplant surgery.

United Kingdom

National Health Service (England) is public but some private hospitals and clinics in the United Kingdom are medical tourism destinations, especially London. Nevertheless, as at the present time very few UK private hospitals have gone through independent international accreditation (they only have the mandatory registration with the UK's watchdog, the Care Quality Commission), so they have not as yet measured themselves against the best clinics and hospitals elsewhere in the world.

Health tourism in the UK often targets the NHS for its free-at-the-point-of-care treatment, allegedly costing the NHS up to £200 million.

See also

• Wellness tourism

References

• Businesses May Move Health Care Overseas (Washington Post)
• CBC News on "Medical tourism: Need surgery, will travel"
• A Cut Below: Americans Look Abroad for Health Care (ABC News)
• Medical Tourism, 60 Minutes (CBS News)

External links

• Listings of medical tourism websites - Open Directory Project