Medical tourism

Medical tourism refers to people traveling to a country other than their own to obtain medical treatment. In the past this usually referred to those who traveled from less-developed countries to major medical centers in highly developed countries for treatment unavailable at home. However, in recent years it may equally refer to those from developed countries who travel to developing countries for lower priced medical treatments. The motivation may be also for medical services unavailable or illegal in the home country.

Medical tourism most often is for surgeries (cosmetic or otherwise) or similar treatments, though people also travel for dental tourism or fertility tourism. People with rare conditions may travel to countries where the treatment is better understood. However, almost all types of health care are available, including psychiatry, alternative medicine, convalescent care, and even burial services.

Health tourism is a wider term for travel that focus on medical treatments and the use of healthcare services. It covers a wide field of health-oriented, tourism ranging from preventive and health-conductive treatment to rehabilitational and curative forms of travel. Wellness tourism is a related field.

The first recorded instance of people travelling for medical treatment dates back thousands of years to when Greek pilgrims traveled from the eastern Mediterranean to a small area in the Saronic Gulf called Epidauria. This territory was the sanctuary of the healing god Asklepios.

Spa towns and sanitaria were early forms of medical tourism. In 18th-century Europe patients visited spas because they were places with supposedly health-giving mineral waters, treating diseases from gout to liver disorders and bronchitis.

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, in the United States, a liver transplant that may cost $300,000 USD, would generally cost 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, for example, an estimated 782,936 Canadian patients spent an average waiting time of 9.4 weeks on medical waiting lists in 2005. Canada has also set waiting time benchmarks for non urgent medical procedures, including a 26-week waiting period for a hip replacement and a 16-week wait for cataract surgery.

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: Canada, Cuba, Costa Rica, Ecuador, India, Israel, Jordan, 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 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 organizations. 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.

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. There are a number of accreditation schemes available based in a number of different countries around the world.

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.

A British scheme, QHA Trent Accreditation, is an active independent holistic accreditation scheme, as well as which monitors the success metrics and standards of almost 500,000 medical clinics worldwide.

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 or QHA Trent. As a result of competition between clinics for American medical tourists, there have been initiatives to rank hospitals based on patient-reported metrics.

Medical tourism carries some risks that locally provided medical care either does not carry or carries to a much lesser degree.

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 are sunburned 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.

Patients sometimes travel to another country to obtain medical procedures that doctors in their home country refuse to perform because they believed that the risks of the procedure outweigh the benefits. Such patients may have difficulty getting insurance (whether public or private) to cover follow up medical costs should the feared complications indeed arise.

Legal issues
Receiving medical care abroad may subject medical tourists to unfamiliar legal issues. The limited nature of litigation in various countries is a reason for accessbility 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.

Medical tourism guide

Medical Tourism is a growing concept worldwide where people travel to another country for medical treatment at lower cost or to enjoy a vacation along with their treatment.

Typically, medical tourism involves residents of high-income countries seeking medical treatment in low-income countries; often the costs are much lower. Residents of countries with national health care schemes – such as Canada and Great Britain – may travel to avoid the long waiting times such schemes sometimes bring. Others may travel for cosmetic surgery not covered by insurance. Also, couples are increasingly seeking fertility treatments abroad. Others have sought more sophisticated surgery, such as cardiology treatments, overseas.

Availability of good low-cost medical services can also be a major factor in selecting a destination for retiring abroad.

Possible benefits
The most obvious benefit is lower cost of treatment. All the professional services — doctors, dentists, optometrists, physiotherapy, lab tests, hospitals, etc. — are generally cheaper in low-income countries. Many related items, such as eyeglasses, dentures or common drugs, are also usually cheaper. However items that have to be imported, such as dental implants or certain drugs, may actually be more expensive.

Many travelers incorporate a short holiday along with the treatment as these also tend to be cheaper than vacations in their home country. Some even retire abroad in an area where they can get good cheap treatment.

Medical tourists sometimes can avail themselves of the best doctors and hospitals of a foreign country. The hospitals/clinics in medical tourist destinations may also be credentialed in first world countries and doctors are sometimes graduates of first-world medical schools.

Waiting lists are sometimes shorter in another country, for those with the means to pay. For example well-heeled Canadians may jump the queue at home by buying treatment in US private hospitals, where specialised care can be had quickly – if money is no object.

Residents of nations which criminalise abortion may find their options less restricted elsewhere; for instance, Irish patients often travel to Great Britain for treatment.

Birth tourism may allow a way around immigration laws or circumvention of mainland China’s one-child or two-child policies; jus soli countries (where anyone born in the country without diplomatic immunity is entitled to birthright citizenship) are the preferred destinations. The number of countries offering jus soli , let alone unconditional ius soli, is dropping. Australia for example abandoned unconditional jus soli in 1986, Ireland and France similarly abandoned it. Outside the Americas, jus sanguinis (citizenship by “blood” or descent) is most common.

In some cases, the foreign hospital or medical facility is actually geographically closer. This can have unintended consequences; many Campobello Island, New Brunswick kids have Maine birth certificates as it’s the only point reachable year-round by bridge, but that dual citizenship leaves these “border babies” liable for United States of America income taxes for life while living as Canadian citizens in Canada. A few decades back when the US military used conscription, these kids could be drafted.

Medical tourism also gives people a chance to incorporate local therapies — India’s yoga and Ayruvedic medicine, Thai massage, traditional Chinese medicine, … — with their ongoing treatments.

Generic drugs
Another reason for seeking treatment abroad can be the lower cost or better availability of some drugs.

As a general rule the more common drugs, e.g. most things on the WHO list of essential medicines, will be considerably cheaper in low-income countries. On the other hand, imported items such as dental implants and newer or more unusual drugs are often more expensive. There may also be differences in prescription rules; for example in China Viagra (or a Chinese copy?) and many antibiotics are available over-the-counter. In the Philippines, Viagra and Cialis are often sold by vendors walking around tourist areas; like their Rolex and Rayban products these are likely not authentic, so they may be quite risky, but they are cheap (under a dollar a pill if you bargain well) and they do work.

The most blatant example of an enormous price difference is Harvoni, the first of a group of new drugs for Hepatitis C. Previous treatments involved injections, often had quite nasty side effects, and gave only about a 60% chance of curing the disease; Harvoni is taken by mouth, has fewer side effects, and cures well over 90% of patients. Unfortunately, in the US it is patented and sells for about $1000 a pill, over $80,000 for the usual treatment of 12 weeks at one pill a day. At least two other drugs with similar properties are now on the market and cost less, but still in the tens of thousands. Many insurance schemes — including the British National Health, Canadian provinces, and many insurers in the US — will not pay for these treatments unless you are very ill, so some patients go untreated and may spread the disease.

India refused to grant the Harvoni patent on grounds it contained no significant original work — the key part of the research was done at a British university — and in India the whole 12-week course of treatment costs about $1000. This is not some dubious knock-off from a ‘pirate’ vendor; the Indian companies involved are large and reputable, and are licensed by the original developer. A 12-week vacation in India, including air fare, good hotels, and Harvoni treatment would quite likely cost less than Harvoni in the US or Europe, and other countries such as Egypt and Bangladesh also have Harvoni at low cost. There are also several groups who offer Indian Harvoni worldwide by mail order; see FixHepC for links.

For other things, the issue may be availability rather than cost. It can take years for a new or experimental treatment to prove its worth and obtain regulatory approval, and it may be approved in some countries long before others. The dengue fever vaccine, for example, was approved in Mexico, Brazil and the Philippines in late 2015 but as of mid-2017 there are many countries where it is not yet approved. Cuba has a lung cancer treatment called CimaVax that (as of mid-2017) is available only there and in a few other Latin American countries; other countries are running tests but are unlikely to approve it soon.

Important considerations
Be sure you are allowing enough time in your travel to receive follow up care. You may need to stay days or weeks beyond the date of the medical procedure itself. Be realistic about the finances of medical tourism. Sure the medical treatment itself may be cheap. But when you add on airfare, hotels, taxis, restaurants – all in an unfamiliar city – the actual cost may be close to what you would pay at home.

Next, involve your home doctor in your plans! Having major surgery in a faraway country is not a decision you should take lightly. Research – what sort of questions should you ask your doctor about this procedure? How is the procedure typically performed, and will it be done this way where you travel? Who credentials doctors and hospitals in your destination country, and what credentials do your intended providers have? You should also determine what level of follow up care your procedure may require – in the days, weeks, and even years after the procedure. Who will provide this follow up care?

If a specialised procedure entails possible medical complications, your budget should permit a follow-up trip to your distant specialist. For instance, if gender reassignment surgery in Canada is done only in Montréal, a British Columbia patient might incur an unexpected 4600km road trip to revisit the original surgeon.

Not all medical tourism is enjoyed by patients travelling away from their home country, or travelling to a third world region. For instance, migraine surgery is performed only in the US, and attracts patients from the Middle East and Africa, since their surgeons aren’t able to perform this. If you are considering travel from within your country or outside of it, be sure to explore all of your options. Seek assistance from many sources in locating the right doctor and the right country.

Don’t be surprised if insurance which would have fully paid for a medical procedure at home refuses to cover (or only partially covers) the same treatment abroad. Even within the same country, some provincial health insurance plans only reimburse what they would have paid in-province, leaving the traveller out-of-pocket. Insurers are also likely to refuse to cover transportation. Border crossing can also be complicated by the need to carry prescribed medicines; a prescription validly issued by a practitioner in one country may be meaningless in another.

Patients seeking treatment for mental health conditions, communicable disease or street drug addiction may encounter issues with immigration authorities if travelling internationally. “I’m Toronto mayor Rob Ford and I’d like to see a Chicago doctor about my crack cocaine problem” is the wrong thing to tell the US border patrol, unless the intention is to immediately turn back to seek medical treatment in-province. Gravenhurst is charming this time of year?

Consider the languages you speak and what is spoken in your country. In some countries, such as Singapore, Malaysia, India, the Philippines and South Africa, most educated people speak English. This can be an important consideration. Having a common language is not necessarily enough, though, if it is not the native tongue for both of you (“fluently” can mean different things), or you or the personnel speak it with a strong accent or with a strange jargon. There may be subtle nuances you’d better be able to convey and understand.

Lastly confirm, and double check, your plans. How can you contact family members while abroad? Do you need a special visa or proof of ability to afford treatment in order to enter your destination country?

Stay safe
In the past, some discredited or bogus doctors set up shop outside US borders to promote dubious or dangerous treatments or outright scams (alleged cures for cancer, lengthening body parts, etc.). Medical tourism today is far removed from these scammers but one must still be vigilant. At the very least, see a trusted doctor in your home country and discuss your plans for overseas treatment.

Reputation counts in medical treatment overseas. Look for top quality hospitals and clinics with well known doctors.

If anything goes wrong, don’t be surprised if your local doctor is reticent to do anything to attempt to “fix” the work done by your foreign practitioner. This is a medical liability issue; local doctors fear lawsuits if an attempt to repair another surgeon’s bungled procedure makes things worse.

Realize that, should a worst-case scenario occur, your legal avenues for making a malpractice claim or filing a lawsuit will be greatly reduced and often nonexistent. Freedom from frivolous lawsuits and huge insurance premiums are one reason why some doctors choose to practice overseas and can offer low cost treatments. On the other hand, this type of legal environment makes seeking doctors of good reputation all the more important.

Travellers might be impaired during recovery; see travellers with disabilities.

Source from Wikipedia