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New study numbers US medical tourists in thousands not millions

US passport and currency

A new study “Medical Tourism Services Available to Residents of the United States” published in the Journal of General Internal Medicine casts doubts on many of the claims made about the size of the medical tourism market and concludes that “the number of Americans travelling overseas for medical care with assistance from medical tourism companies is relatively small”.

Published in December’s issue of the Journal of General Internal Medicine, “Medical Tourism Services Available to Residents of the United States” is a report on the businesses and business practices of companies promoting and facilitating medical tourism to US patients and the types and costs of procedures being offered. In late 2008, the researchers conducted a telephone and email survey of businesses engaged in facilitating overseas medical travel for US residents. They collected information from each company including: the number of employees; number of patients referred overseas; medical records security processes; destinations to which patients were referred; treatments offered; treatment costs; and whether patient outcomes were collected. 63 medical tourism companies were selected for inclusion and 45 (71%) completed the survey.

13,500 US medical tourists from 45 businesses since start up

The 45 companies involved had referred an average of 285 patients overseas since start up (not in the previous twelve months).  The survey recorded a total of approximately 13,500 US medical tourists in total for all 45 businesses since they started in business. The most common overseas countries that companies reported referring patients to were India, Costa Rica, and Thailand though many other countries were mentioned less frequently including Malta, Israel, Spain and Germany. The most common medical services utilized by overseas medical travelers were orthopedic procedures, cardiac procedures, infertility treatment, and cosmetic surgery. (The study specifically excluded companies that focused exclusively on dental care).

The authors highlight the significant difference between their grand total of 13,500 US medical tourists travelling via 45 medical travel facilitators and the “number of articles, studies, and reports (that) have suggested that between 500,000 and 2,000,000 Americans travel overseas each year for medical care.” They believe that their study mirrors and supports the kind of numbers quoted by McKinsey & Co (Mapping the Market for Medical Travel) who estimated “the current market at 60,000 to 85,000 inpatient medical travelers a year—numbers far smaller than others have reported.”

The study authors propose that the discrepancy in the estimates of the size of the overseas medical market is related to the following factors:

1.       Estimates of a much larger US medical tourism market were proposed by parties with personal and/or financial interests in the overseas medical travel market.

2.       Their study did not attempt to measure the number of Americans travelling for dental care. This is believed to be quite a high proportion of the US outbound market, particularly cross border to Mexico and to South America. According to Sandra Miller at Health Travel Technologies, “We process more than 600 inquiries per months, and send more than 100 patients a month abroad........We send 20 dental patients per month to top notch dental clinics in Mexico, Costa Rica, the Dominican Republic and El Salvador.”

3.        Their study did not attempt to measure the number of Americans who may have traveled overseas without using the services of a medical tourism facilitator. Estimates of how many medical tourists use a facilitator vary widely. Some US estimates put this as low as one in five patients who use the services of a facilitator.  (Research on UK medical tourists put this figure as around one in three – Treatment Abroad Medical Tourism Survey 2008).

The authors point out that even when items 2 and 3 above are factored in, “the market may be somewhat smaller than prior studies have estimated”. They also point out that two years after conducting the interviews, they found that 15.6% (7 of 45) of companies that completed the initial interviews no longer had functioning websites and thus were presumed to no longer be in business.

It’s also worth pointing out that the survey was restricted to medical tourism facilitators who had a US phone number. 97 facilitators were excluded from the research for this reason. This in effect excludes many Mexican, South American and Asia based facilitators who handle US patients.

Cost savings for medical travel less than claimed

The study’s findings related to the cost of overseas medical travel also warrant mention. The authors report that “overseas medical costs for several procedures were generally similar to combined hospital and physician payments made by Medicare for the same procedures.” For example, according to the study, a heart bypass surgery costs an average of $18,600 outside the USA. Within the USA, Medicare pays around $21,000 for the procedure. They conclude that “the take-away message is that the expected savings from overseas medical care is dependent on what, typically uninsured, patients might be expected to pay if they instead purchased this care in the US” and “the fact that overseas charges are reasonably close to Medicare rates suggests that there may be significant opportunity for US providers to compete with offshore facilities, in some situations, by offering highly discounted prices to uninsured American patients.”

IMTJ comment

We welcome this attempt to put some validity on the size of the US outbound market. The study is one of the first to approach the thorny issue of US medical tourism statistics by asking medical tourism businesses how many patients they actually handle rather than by creating “guesstimates” based on what people say they might do. It also puts some of the oft quoted predictions of “6 million US medical tourists in 2010, 10 million by 2012” etc etc in a different light.

A similar approach was adopted in 2007 in a study by Treatment Abroad in which facilitators, hospitals and clinics were asked to provide numbers of UK patients treated. This study put the number of outbound UK medical tourists at around 50,000 (similar to numbers recorded in the UK’s International Passenger Survey data.)

However, the new study does have its flaws – sampling bias, exclusion of dental care, exclusion of self arranged medical travel – which undoubtedly impacts the overall number of medical tourists that it counts. Nevertheless, even if we allow for these flaws and factor in the “missing” patients, the study suggests that the annual outbound medical tourism patient numbers for the USA are perhaps in the region of 100,000 to 200,000 at best, rather than the millions that have been mooted elsewhere.

The study highlights the areas of healthcare that are driving US medical travel – cosmetic (and obesity) surgery, stem cell treatment, IVF treatment, cosmetic dentistry and other non-insured areas which will not be covered by “Obamacare”. It does not analyse the clear ethnic trend in medical travel in the USA and elsewhere  - people who are travelling from the country of residence to their own, their father's or their grandfather’s nation of birth. This is a significant driver of US medical travel:  Mexicans to Mexico, Hispanics to Latin and South America, Asians to Asian countries, Koreans to Korea etc.

Although, they are now in effect two years out of date, the findings of “Medical Tourism Services Available to Residents of the United States” reflect what many people within the industry believe is closer to the truth in terms of medical tourism patient numbers. i.e. thousands not millions.  Many countries, their governments and hospital providers have come to believe that the US market represents a rich source of patients but have been disappointed by their lack of success. They may need to revise their expectations and rethink their strategy.

Source article: Medical Tourism Services Available to Residents of the United States

Authors: Brandon W. Alleman, Tana Luger, Heather Schacht Reisinger, Rene Martin, Michael D. Horowitz and Peter Cram
Journal of General Internal Medicine, December 2010

A PDF of the full article can be downloaded from SpringerLink at a cost of 34 Euros.

Date published: 5 January 2011

Comment

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Comments provided below do not represent the views of IMTJ. Comments will be published "as is" and will not be edited by IMTJ staff. IMTJ is hosting these comments, and is not  undertaking an editorial role in the content of these comments. However, it is editorial policy not to publish comments which have been submitted anonymously.

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This article sounds sensible to me. Everybody knows many hospitals and countries around the world try to hype their numbers in order to attract patients, and some are deliberately lying about them.
For example, Bumrungrad International Hospital in Bangkok officially claims in its website, in brochures, handouts and in speeches by their executives that they have over 400,000 international patients every year. What they actually do is count each patient 10, 20, 30 times - when you have an X-ray you are one patient, when you have an ultrasound you are another patient, you get a CBC you again are a diffrent patient, etc. You have to look at the integrity of an institution very carefully.
Bumrungrad also claims it is "the largest private hospital in Southeast Asia, with 554 beds". Another
outright lie, one they have been peddling for over ten years. In the Philippines alone, five private hospitals (Chong Hua Hospital, St. Luke's Medical Center-Quezon City, St. Luke's Medical Center-Global City, The Medical City, Chinese General Hospital) are bigger than Bumrungrad.
When confronted with these outrageous claims and facts at a conference earlier this year, a former marketing head of Bunrungrad answered: "Yes, but we achieved our objectives!" Really galling...
Why is nobody raising a stink about this? My tragically funny answer: there is honor among thieves...

Joe Ledesma (27/08/2011 06:52:09)

I want to settle my own Medical tourism/ Facilitator company, Can any body help me on this....? THANX

Raheem khan (15/06/2011 19:52:58)

I am going for the second time to Southeast Asia for various procedures. None are actually surgery. I go there because I don't trust, can't afford treatment in places I live or work. Not counting me as a medical tourist doesn't make much sense to me.

re: wanting a big number: yes, some folks want that. Other folks want a small number (like the publishers of this study, for example). Should we trust the latter any more han the former?

B M (19/01/2011 03:24:09)

I think that Jeff Schult has summarised the issues related to this study very clearly:

"these numbers only mean something when they are accompanied by methodology and a summary of what is being counted...... If you want a big number -- and the media wants a big number and people who write business plans want a big number -- you have to count dental. You have to count regional medical tourism (i.e., dental between U.S. border states and Mexico.) You have to count expatriates."

It comes down to "what is a medical tourist" and "how do you count them?".

If we say that a medical tourist is an individual who travels outside of their own country for surgery or elective treatment, then the numbers of US medical tourists are in the thousands. BUT this excludes:
- dental tourists
- spa and wellness travellers
- "accidental" medical tourists (business travellers and holiday makers who fall ill while abroad)
- expatriates who access healthcare in a foreign country.

The best attempt that I have seen at defining and categorising "health tourism" (as opposed to medical tourism) and its various segments is by Constantine Constantinides - see www.healthtourism8.com.

Regarding the comment " it was estimated and also was reported in CNN by Sanjay Gupta that there were around 600,00 (careful how you read...or mis-read this number!) patients traveling to India alone". The difficulty here is that this is a CNN health correspondent reporting on what he has been told without questioning the data or the motivation of those who are giving him the numbers. Having said that, what he actualy reported was this: " in India, the Apollo Hospitals Group says it has treated more than 60,000 foreign patients in the last five years". (Be careful not to read this as 600,000 in one year). That's probably quite a sensible and honest number - 12,000 foreign patients per year (from all countries). How many of these 12,000 a year were from the US? In reality, probably quite a small

Keith Pollard (07/01/2011 10:57:53)

Sandra
See email. Your comment re the volume of dental patients was taken from a statement that you made which is in the public domain. It was used to put the size of the dental market (omitted from this study) in perspective.

Keith Pollard (07/01/2011 09:57:50)

I have been trying to break out the “why” of the problem too but come to slightly different conclusions. On the provider side…offshore hospitals should be spending some marketing money but more importantly, in my view, they should choose their strategies (my thinking in the IMTJ is here: http://www.imtjonline.com/articles/2010/has-health-travel-reached-maturity-30081/?locale=en . The delay in undifferentiated positions creates tons of global customer confusion, but even more so, on the U. S. side because of our domestic situation.

On the U. S. customer side, I think the problems are customer confusion and customer burden. I posted what I'll call “draft requirements” here http://medblogcontest.com/blog/8/?p=232 and will keep it updated if anyone wants to add to the thinking. I call the U. S. healthcare situation The Rat-King (after the German myth) and know this out of my own experience. In late November, I was diagnosed as needing hip-resurfacing and used the diagnoses as reason to shop around domestically and globally as a typical customer.

My experience is that it is very, very difficult (and in some cases, impossible) to get a cash price from a U. S. hospital on a hip surgery procedure. It took many hours of detective work. Totally Rat-King and high customer burden. I attribute this to hospitals wanting to keep switching costs high and also to fear of being sued. Health reform will help with transparency and teaching Americans to be smart health care consumers but there is a long way to go.

Cross-border…it is easier to get some information but still very, very difficult to get enough info that I could say to myself in good faith that I knew enough to move forward and get on an airplane to have surgery (even though I write books on Health Travel).

When I communicated with offshore hospitals with requests for info and pricing I got one or two of the below. I think the way to lower customer burden and increase conversion of inquiries to act

Scott Frankum (07/01/2011 04:26:06)

The study, while it may provide a more reasonable estimate of actual medical travelers, does not provide a good assessment of cost savings. The study compared prices to Medicare rates. Medicare pays US hospitals significantly BELOW COST. US hospitals then offset Medicare losses by overcharging the commercial insurance market.

Those prices paid for joint replacement and cardiac procedures by large US companies and commercial insurers are far higher (typically $30-40$K) greater than in Thailand, Malaysia, India and other countries.

While Obama, Pelosi, Reid and Sebelius argue that insurance companies are raising premiums too much, these companies are actually just subsidizing Medicare.

There is a very real market for outbound medical tourism from the US.

Todd Madden (06/01/2011 21:03:51)

I don't remember anyone asking me at IMTJ if it was OK to quote me in this article - someone please contact me to discuss this, because I would not voluntarily support conclusions from an article with this ridiculous slant and lack of context.

Sandra Miller (06/01/2011 18:43:59)

What "we all know," really, is that these numbers only mean something when they are accompanied by methodology and a summary of *what is being counted.*

And that is, in fact, provided here. They are counting non-dental patients that make arrangements through medical tourism/facilitator companies. And those numbers have been very low for years and represent a tiny percentage of people who travel for medical or dental care.

That was true when I wrote a book about the subject in 2006 and it's true now. If you want a big number -- and the media wants a big number and people who write business plans want a big number -- you have to count dental. You have to count regional medical tourism (i.e., dental between U.S. border states and Mexico.) You have to count expatriates.

Then you get a big number, but it doesn't mean anything for business planning purposes.

If you don't believe me, go to the hospitals and facilities and see how many Americans are actually there at any given time. The numbers out of the Far East are particularly suspect because they're fueled by government-sanctioned and supported PR. India has been telling the same story for years now.

Jeff Schult (06/01/2011 17:46:47)

The authors of this piece should be ashamed for such shoddy work........really now.

Joseph Cronin (06/01/2011 17:37:01)

We all know that previously it was estimated and also was reported in CNN by Sanjay Gupta that there were around 600,00 patients traveling to India alone. Deloitte & Touche estimated similar number. Real number may be some where in between. It is very tough to get a real number at this point.
www.TourNCare.com
Online Medical Tourism Community

Dha Kur (06/01/2011 03:40:44)