Two New York academics consider some of the concerns raised in the USA over the development of medical tourism. They raise the question, “Do the benefits of saving on costs in the short term out-weigh the risks associated with medical tourism in the long term?” The article identifies the dilemmas affecting patients post-surgically due to a lack of follow-up care and the high cost to risk scenarios that may develop due to complications once they are discharged. The authors challenge the assumption that patients actually save on costs and identify ways the United States health care system can effectively deal with this trend. A different view of medical tourism….. but one that those within the industry should acknowledge.
Abstract
As the price of health increases, more and more people are looking elsewhere to receive affordable health care. Reports of significant cost discounts, shorter waiting times, improved service by health personnel and exotic vacations seem to be driving Americans abroad to seek health care. Theories have also emerged in the current literature discussing planned behavior as a key factor in determining whether an individual would seek treatment outside the United States. The United States medical community questions the quality and safety of outsourcing medical care in developing countries. Public health experts express concern over the accreditation of these facilities, the lack of malpractice laws, the purity of blood banks and the absence of follow-up care post-surgically. As health reform looms upon the United States, experts believe that it will not stop the momentum of medical tourism. Identifying the dilemmas affecting these patients post-surgically, due to a lack of follow-up care and the financial implications that may develop due to complications once they return home, is essential in helping the United States health system effectively deal with this trend.
Introduction
Medical tourism has emerged as a global health care phenomenon that has been estimated to generate sixty billion dollars worldwide (Evans, 2008). The phenomenon refers to traveling to another country in the search of affordable and convenient health care (Cheung & Wilson, 2007). As this trend appears to be progressively gaining popularity among people from the United States, it is creating a series of dilemmas in the global healthcare market, such as high cost-to-risk scenarios.
Many Americans are traveling abroad for a number of medical services that range from cosmetic surgery to organ transplantation. Popular destination areas such as Cuba and other Latin American countries, Singapore, Thailand, Malaysia and India are among developing nations that tourists are flocking to for better health care options (Jose & Sachdeva, 2010). A recent report (Carruth & Carruth, 2010) states that the number of Americans traveling overseas for various health-related treatments has been estimated at 750,000 citizens. As medical costs in the United States continue to escalate (approximately eight percent per year), both patients and some insurers are shopping overseas for less expensive treatments (Brown, 2008). The millions of Americans whom are uninsured and seeking prompt medical care may have provoked the emergence of such a phenomenon. This population of adult, non-Medicare/Medicaid eligible citizens represents a group of individuals whom are either in a very low-income bracket or are not offered employer-sponsored insurance as part of their compensation package (Burkett, 2007).
From the patient’s point of view, medical tourism may come as a relief with shorter waiting times and lower costs (Mattoo & Rathindran, 2006). In the United States, advocates of medical tourism explain that traveling to countries in Asia provides a blanket of security for many uninsured and underinsured Americans who cannot afford to purchase expensive medical procedures at their local hospitals (Turner, 2007).
According to Jose and Sachdeva (2010), a patient could pay $22,000 in Thailand for a heart bypass surgery, as opposed to $133,000 in the United States; and knee replacements in Singapore will cost $9600, as compared to the United States’ cost of $53,000. Plastic surgery in the United States can be costly, however, in Columbia the same procedures can be obtained for less than a fourth of the cost in the U.S. (Carruth & Carruth, 2010). These significant cost discounts may be appealing to the price-cautious consumer; however, these discounts may be coupled with significant life-threatening risks. In addition, medical tourism may encompass other important public health risks such as a lack of patient selection criteria and best-practices guidelines, a lack of continuity and/or follow-up care and the lack of auditing of major health care concerns by governing bodies; these are all essential elements of a traditional and structured health care model (Cheung & Wilson, 2007). The question raised is, “Do the benefits of saving on costs in the short term out-weigh the risks associated with medical tourism in the long term?”
As thousands of Americans contemplate having their medical procedures performed overseas, the American health care system can no longer ignore it and effectively deal with this new global market trend. The following paper will evaluate the multiple reasons why American citizens decide to travel abroad for medical and surgical care, specifically for orthopedic and cosmetic surgery. The theory of planned behavior is used within the paper to explain and identify why an individual would seek care outside his/her known environment. The paper also identifies dilemmas affecting these patients post-surgically due to a lack of follow-up care and the high cost to risk scenarios that may develop due to complications once they are discharged. The paper will challenge the assumption that patients actually save on costs or increase costs to the health care system in the United States. Finally, the paper will identify ways the United States health care system can effectively deal with this trend.
Background
Traveling abroad for health care is not a novel idea. In our history as human beings seeking to improve health, there have been those individuals who sought spas, mineral baths, pioneering therapies, and improved climates. For example, from the late 19th to the mid-20th centuries, Saranac Lake in the Adirondacks was the world’s foremost tuberculosis treatment center because of its clean and “pollution-free” climate (Gray & Poland, 2008). It was known as the wilderness cure, and for many years sick individuals would travel to upstate NY to seek care at these facilities. Those who did travel to seek new treatment therapies were usually members of the upper social classes. Presently, in the 21st century, we find individuals in the middle class traveling from developed countries to developing nations, often to seek life saving procedures (Gray & Poland, 2008). According to York, the American Medical Association states that the mass exodus of uninsured and underinsured Americans traveling abroad to seek medical attention is a sign that the United States health care system is in crisis. In 2009, 50.7 million Americans were uninsured and many more with restricted policies traveling abroad (US Census, 2009). For those who do have insurance, expensive health care treatment can also have some devastating outcomes. According to a bankruptcy study performed by the Harvard Medical and Law School, 50% of the United States’ bankruptcies in 2001 were due to outstanding medical bills (York, 2008). It is estimated that individuals seeking care in a foreign country can save anywhere from 50-80% in cost (Burkett, 2007). However, other than costs what factors actually drive an individual to travel to a foreign developing country to obtain medical and surgical care from unfamiliar doctors?
The theory of planned behavior
Ajzen’s theory of planned behavior is used to explain and identify why an individual would engage in certain actions, for example, seeking care outside his/her known environment (Ajzen, 1991). Although medical tourism is not a new industry, the direction of travel of many medical tourists has changed in recent years. Affluent people from developing countries once traveled to developed countries, such as USA and countries in Europe, to seek out medical care; however, more recently individuals are traveling from developed countries to developing countries seeking certain types of medical treatments (Reddy et al., 2010). Although cost is an important driving factor, little is known about the beliefs and attitudes of those patients traveling abroad to seek medical care. According to Ajzen’s theory of planned behavior, individuals are more likely to pursue an action if they feel they have control over performing it (Ajzen, 1991). The theory predicts behavioral intention by: evaluating individual attitudes toward the behavior; perceived belief that those important to the individual would approve of the behavior; and finally, the perception of control over the behavior (Reddy et al. 2010). Reddy and colleagues found that if a person had a positive belief toward the behavior, had approval from family or friends that were important to them and felt that they had the ability to go through with it, and then they were more likely to travel abroad for medical tourism (Reddy et al., 2010).
The theory of planned behavior may be a useful tool to consider when attempting to educate the public about medical tourism. Concerns over substandard care, follow up care and surgical complications resulting from lengthy flights may affect an individual’s perception of the behavior of medical tourism. However, the discounted costs and foreign destinations may also influence individuals considering medical tourism in making a decision. Advantages as well as disadvantages must be analyzed and utilized in making informed decisions regarding medical tourism.
The benefits of medical tourism
There are a number of positive patient reports regarding medical tourism that can be found on numerous websites. According to one article, patients report first class, luxurious treatments received at foreign hospitals. Obtaining a necessary surgery at less than half the rate in the United States, and at the same time experiencing an exotic vacation makes the choice of a foreign destination an attractive option. In response to this phenomenon in healthcare, many entrepreneurs have taken advantage and created a new industry. It is known as the ‘medical concierge company.’ It is a company that will set up all the minute details of the trip to the foreign country. It includes everything from advising the patient on appropriate facilities in the appropriate country based on their medical condition, to handling all travel arrangements, including air fare and hotel stay, setting up teleconferences with the attending physician in the surgical destination, and sending appropriate medical records (York, 2008). The company acts as a medical liaison between the patient, physician and the medical facility. In addition a case manager is also stationed at the destination to help handle any issues that may rise. This case manager is usually an American living in the destination country.
Although the positive objective of medical tourism is to provide the millions of uninsured and underinsured Americans with healthcare, there are other benefits to be gained as well for the patient and the host country. Patients also report a more positive experience in their hospital stays, with longer admittance into the hospital and personal nursing care as opposed to the short hospital stays in the United States and under staffed nursing population. Doctors from these foreign hospitals are supported by more nurses, patients are provided with single private rooms, and a single nurse is appointed to each individual patient, twenty-four hours a day (York, 2008).
There are also some minor benefits to the public and private sector of the United States health care system. State legislators are also realizing the financial benefits of medical tourism by proposing bills to provide incentives for state employees to travel abroad for medical procedures, (Forgione & Smith, 2006). Several United States corporations and self-employed citizens are considering medical outsourcing because of rising health costs as well. Concierge companies, such as Satori World Medical, aim their services to insured workers with high deductibles (Rhea, 2009). Physicians, especially those who are foreign nationals and practice in the United States, are taking advantage of this new market trend as well by obtaining licensure in multiple countries with admitting privileges at hospitals in more than one country (Forgione & Smith, 2006).
Economic impact
In regards to the host country, the major benefits include bringing state of the art equipment, such as CT, MRI, and other advanced imaging machines, that may provide better care for the individuals of developing countries that otherwise would not be obtained in their region. For these individuals, traveling for medical care is not always an option because of low monetary resources. With the presence of skilled healthcare providers and financial resources, medical tourism allows host countries to provide better care to the members of the local community who would otherwise have limited or no access to such modern facilities (Horowitz and Rosenweig, 2007). In addition, medical tourism provides a source of economic stimulus for the developing countries, as foreigners pour money not only into the healthcare system, but also into touristic activities. South Africa, for example, has made a success out of selling medical services combined with excursions such as safaris (Horowitz & Rosenweig, 2007).
One of the reasons why medical services are so inexpensive in these countries relates to the country’s economic level (Horowitz & Rosenweig, 2007). Medical costs need to be appropriate for the economic status of the host country, in order to be somewhat affordable to its citizens. India and Thailand are reported as being the number one destination spots for medical surgeries that include mostly cardiac surgery and orthopedics (Horowitz & Rosenweig, 2007). These countries house large, modern facilities staffed by licensed physicians trained in many complex surgeries (Horowitz & Rosenweig, 2007).
A second reason why these foreign hospital services are so affordable is the lack of “legal remedies for malpractice” (York, 2008). Malpractice laws are written to protect doctors and facilities and “provide patients with some compensatory relief, if the health care professionals deviate from accepted practice standards and cause injury to patients” (Forgione & Smith, 2006). Finally, the third reason for inexpensive medical services is the lower pharmaceutical costs (Forgione & Smith, 2006). It is reported that many of the pharmaceuticals available overseas in developing countries are counterfeit medications. This poses a problem, as many patients will most likely need medication, whether for pain or antibiotics to prevent infection, after surgery.
Concerns about the quality of care
As the rising cost of healthcare continues to drive Americans out of the states and abroad to shop for more affordable medical procedures, the quality of care of these facilities comes into question. Many of these countries are considered endemic to a number of infectious and parasitic diseases that include malaria, yellow fever, dengue fever, dysentery, typhoid, and HIV, just to name a few (Forgione & Smith, 2006). Although recent studies have ranked the United States 37th in certain quality of care measures, medical tourism still raises questions regarding the quality of care and reasons for lower costs of these medical services (Forgione & Smith, 2006). Establishing legitimacy among these foreign destinations proves to be difficult, while ethical concerns over the safety and quality of care are questioned. In particular, experts question who can be held accountable for post surgical complications and how to deal with follow up care concerns.
The Joint Commission, formerly known as the joint Commission on Accreditation of Health Care Organizations, developed the Joint Commission International (JCI) to help accredit hospitals worldwide (Fried & Harris, 2007). One country in particular, India, has benefited greatly from medical tourism. Tourism, overall, has contributed to 5.9% of the GDP (Jose & Sachdeva, 2010). It is estimated that 12% of foreign travelers traveled to India with the intent to obtain health care treatment (Jose & Sachdeva, 2010). Medical tourism in India is projected to be a $2.3 billion industry with an annual growth rate of 30% by 2012, a 18% increase from 2002 (Jose & Sachdeva, 2010) The Government of India (GOI) has recognized the potential economic impact and has gone to great lengths in order to raise their quality standards and attract more clients. The GOI has encouraged periodic renewal of registration of medical personnel and has undergone accreditation with the JCI (Jose & Sachdeva, 2010). Other accrediting agencies include the Trent International Accreditation Scheme in the U.K. and the International Society for Quality in Health Care. Both of these agencies are responsible for accrediting many medical facilities around the world and claim that their physicians are highly trained in the United States or are U.S. board certified (Unti, 2010).
However, although positive reports by countries like India assure high quality standards, many at the American Medical Association complain that the standards, by which these foreign medical facilities are graded, are much less stringent than the accreditation panels in America (York, 2008). The guidelines, such as those developed by the JCI, were created and based on the differing laws, cultures and religions of the various countries (Unti, 2010). It does not allow for a fair comparison between hospitals in different countries since the guidelines may at times defer to local laws and customs of those countries (Unti, 2010). Thus, AMA professionals and other experts in the field are not convinced that the foreign facilities are comparable to the quality of care status of the United States healthcare institutions.
Ethical concerns also develop concerning continuity of care or follow up care, specifically in post surgical cases. Quality of care, including follow up care, is necessary in order to produce quality outcomes (Ben-Natan et al., 2009). What happens when a patient is sent home post surgery and experiences complications? There are a number of risks to the traveling patient associated with medical tourism. Lack of malpractice laws, lengthy flights that can create conditions for developing deep vein thrombosis, and the purity of blood banks of developing countries can hold many risks to patients undergoing surgery (Forgione & Smith, 2007). When patients return home, finding a provider to assist them after they have undergone major surgery outside of the United States may also prove to be difficult.
Medical providers in the United States may encounter problems such as the availability of medical records, follow up care and reimbursement of services (Unti, 2010). Although physicians have the right to decline non-emergency type care, patients should not be punished for seeking care outside the United States. It may prove to be difficult for the physician to obtain adequate and complete records for the patient and a lack of continuity of care could be detrimental to the health of the patient. Liability may also pose an issue if a patient wanted to take legal action due to a complication (Unti, 2010).
Financial implications of medical tourism
The lack of follow up care and continuity of care may result in unanticipated costs for patients. In traditional health care models, physicians stay in contact with the patient and follow up with their care. However, in the medical tourism model there is no incentive for a foreign physician who performed the procedure to continue to maintain management of the patient post-surgically (Carruth & Carruth, 2010). Post-surgical complications that may develop from lengthy flights or post-operative infections may result in increase costs spent on time and money to address the condition (Carruth & Carruth, 2010). Although little is known about the cost implications of post-surgical complications due to medical tourism, several researchers found an increase in morbidity and mortality rates for patients who outsourced care related to organ transplants (Canales et al. 2006).
Health care reform
The signing of the healthcare reform bill: Patient Protection and Affordability Act brought with it the hope of change to the escalating health care costs of the United States. Changes to the federal programs including Medicaid and Medicare were developed in order to expand coverage, control costs and improve payment to providers (Kaiser, 2010). However, healthcare policy experts believe healthcare reform will not alter medical tourism’s momentum unless changes are made to control and lower patient co-payments and provide affordable insurance policies for both uninsured low- and middle-wage earners (Rhea, 2009). Further, experts believe price transparency in the United States can never match those offered in foreign countries because “the cost of doing business is more expensive in the U.S.” (Rhea). Compared to the destination countries, materials in the United States cost more, while physicians and nurses are also paid more (Rhea, 2009).
Employers in America are also finding it difficult to carry coverage for their employees due to rising premiums. Health care insurance premiums continue to steadily increase and significantly outpace inflation and wages (Kaiser, 2009). With the changes made in the Patient Protection and Affordable Care Act, employers with 50 employees or more will be required to offer health insurance coverage or pay a penalty fee (Kaiser, 2010). The change may drive corporations to seek healthcare abroad for their employees in order to find financial relief, especially in today’s economically challenging times. Private insurers are recognizing medical tourism and providing reimbursement (York, 2008); however, experts agree that developing reimbursement agreements with foreign countries on the matter of medical tourism and Medicare may prove to be difficult (Rhea, 2009). In the United States, Medicare reimbursement is dependent on DRGs (diagnostic related groups) in order to track patient care and bill appropriately (Kaiser, 2007). However, the differences that lie in methods of reimbursement between countries are multiple. Mexico, for example, does not require the same system for reimbursement; in addition the laws in Mexico vary to that of the United States in the matters of fraud, abuse and conflict of interest (Rhea, 2009). Nevertheless, opponents of reform see an opportunity in medical tourism which can boost the phenomenon’s momentum.
The emergence of healthcare reform has prompted some to think that it will bring with it universal healthcare coverage as well as the ‘problems’ associated with a government funded healthcare system (Rhea, 2009). If as they fear, there are longer waiting times and delays for medical interventions, this could spark interest in traveling abroad for quicker access, especially for those wealthier patients (Rhea, 2009). These behaviors have been noted in countries such as Canada and the United Kingdom, in which patients decide to take control of their care by traveling overseas (Matoo & Rathindran, 2006).
The effects of healthcare reform on medical tourism may not be immediate; however, what remains certain is that if costs are left uncontrolled, regardless if more Americans are insured, those patients who are not insured will continue to seek alternatives to find financial relief from escalating healthcare costs. Still others may also seek care abroad to find the care they want in a timely manner. It would make more sense to have American patients seek care in the United States.
The literature on medical tourism discusses the various forces driving Americans out of their home country and travelling to distant lands to obtain procedures at less than half the costs. Patients have reported significant cost savings in procedures such as cardiac surgery and orthopedics and have also experienced high quality of care. Savings of 50-80% have been reported in several countries (Burket, 2007) and improved physician bed side manner has also been stated as a benefit by patients. Within the United States, companies have developed methods of benefitting from the medical tourism phenomenon through medical outsourcing and the development of the medical concierge company. Some physicians have also been able to obtain licensure in multiple countries. For the host country, other benefits include an economic boost from the medical tourists and state of the art facilities and equipment. However, experts question the quality of care in these foreign facilities, the lack of continuity of care for the tourists and the negative impact medical tourism can create for the citizens of the host country.
Experts are at odds whether the signing of the health care reform bill, will change the practice of medical tourism. Several believe it will not be affected while others criticize the health care system in the United States and warn that if costs are left uncontrolled or wait times increase individuals will continue to seek out care elsewhere (Rhea, 2009). However, concern over continuity of care has also led experts to raise concerns about the industry of medical tourism. Lack of follow up care in the presence of a complication can result in detrimental health effects and off set cost savings. Future research should investigate whether cost savings off-set costs incurred due to time and money spent addressing complications (Carruth & Carruth, 2010).
Patients of the 21st century are educated consumers. Studies show these patients demand more price-transparency and public reporting of service quality measures (Forgione & Smith, 2006). Overall there does seem to be general satisfaction among individuals traveling abroad for medical treatment (Crooks et al., 2010). With savings of up to 50-80% of costs, medical tourism provides financial relief for those patients who are uninsured or underinsured and do not have coverage for certain procedures. In 2004, 1.2 million patients traveled to India for health care, while 1.1 million traveled to Thailand, both leaders in cardiac and orthopedic surgery (Carruth & Carruth, 2010). It is also projected that $4.4 billion will be spent on medical tourism by 2012 with about half of the money going to India (Carruth & Carruth, 2010). In July 2006, medical tourism was the topic of interest at the United States Senate Special Committee on Aging. The committee discussed some of the potential problems facing the American health care system and the potential role of international health care addressing these problems, as well as, the forestalling of spiraling health care costs in the United States by medical tourism. Proposed solutions on dealing with these issues include: “increasing accreditation in foreign hospitals; regulating health insurance that covers medical tourism; and restricting travel for medical tourism to approved destination hospital countries” (Burkett, 2007). By increasing accreditation in these foreign hospitals, the quality of care standard is increased. This is easily accomplished through international accreditation networks such as the Joint Commission International. By improving and increasing accreditation, it allows Congress to regulate medical tourism and as an added benefit, provide truthful comparisons for the consumer of the foreign hospitals on websites, for example. Also by regulating and restricting travel, it will allow Congress to funnel patients towards those destination hospitals that are fully accredited and meet the higher quality standards. As far as the effect of medical tourism on the United States health care system, outcomes can manifest in a number of ways. There will be a pressure to reduce prices in the United States as more and more citizens seek medical tourism; an increase in price transparency; an increase in quality of care overseas; and finally an increase on the credentialing of physicians, especially in these foreign facilities, (York, 2008). Providers, as well as patients in the United States must be informed and educated on medical tourism and should understand all risks associated with the behavior. Individuals planning on going abroad and seeking care should also advise their doctors and insurance companies to avoid further complicating management of surgery once home.
Conclusion
Medical tourism has become a more accepted form of outsourcing medical services and although there are many benefits, including providing health care to the millions of uninsured and underinsured American citizens, it is essential to rally for healthcare reform in the United States and develop regulations to make medical tourism safer for Americans. Although there is no fundamental right to health care in the United States, there is a right for citizens to choose among health care options and restricting medical tourism is not the answer. Instead, developing regulations that would combine freedom of choice in choosing a foreign facility and at the same time protecting the health and welfare of United States’ citizens seems to be the better method of dealing with this health care phenomenon. Further research is also needed in the area of medical tourism, specifically in the area of tracking of patients’ with post surgical complications and associated financial implications of addressing these issues. Patients may not consider the financial endeavor it may involve to correct a post-surgical complication. Knowing this information before hand can help patients and domestic physicians make better-informed decision regarding medical tourism.
Although a very lucrative global market, medical tourism brings with it both positive and negative factors that both the potential patient and American Congress need to consider before moving forward. Changes such as comparable accreditation processes to that of the United States and other examples mentioned in the paper may help place health professionals more at ease in dealing with patients who have undergone a procedure in a foreign country. Minimizing concern and placing confidence with fear can help decrease the ill-concern for medical tourism specifically among the medical community. Improving medical tourism through further research, policy and practice can also help diminish concern over the safety and quality of the outsourced care. Providing quality care, as well as, secure care, should be the number one objective with regulating medical tourism on the international level for the health provider and the United States.
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