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Medical tourism (also called medical travel, health tourism or global healthcare) is a term initially coined by travel agencies and the mass media to describe the rapidly-growing practice of traveling across international borders to obtain health care. It also refers pejoratively to the practice of healthcare providers traveling internationally to deliver healthcare[1][2].

Services typically sought by travelers include elective procedures as well as complex specialized surgeries such as joint replacement (knee/hip), cardiac surgery, dental surgery, and cosmetic surgeries. However, virtually every type of health care, including psychiatry, alternative treatments, convalescent care and even burial services are available. As a practical matter, providers and customers commonly use informal channels of communication-connection-contract, and in such cases this tends to mean less regulatory or legal oversight to assure quality and less formal recourse to reimbursement or redress, if needed[citation needed].

Over 50 countries have identified medical tourism as a national industry.[3] However, accreditation and other measures of quality vary widely across the globe, and there are risks and ethical issues that make this method of accessing medical care controversial[citation needed]. Also, some destinations may become hazardous or even dangerous for medical tourists to contemplate.

In the context of global health, “medical tourism” is a pejorative because during such trips health care providers often practice outside of their areas of expertise or hold different (i.e., lower) standards of care[4][5]. Greater numbers than ever before of student volunteers, health professions trainees, and researchers from resource-rich countries are working temporarily and anticipating future work in resource-starved areas[5][6]. This emphasizes the importance of understanding this other definition.

History

The concept of medical tourism is not a new one. The first recorded instance of medical tourism 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. Epidauria became the original travel destination for medical tourism.

Spa towns and sanitariums may be considered an early form of medical tourism. In eighteenth 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.[3]

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.[7]

Medical tourists can come from anywhere in the First World, including Europe, the Middle East, Japan, the United States, and Canada. This is because of their large populations, comparatively high wealth, the high expense of health care or lack of health care options locally, and increasingly high expectations of their populations with respect to health care. An authority at the Harvard Business School recently stated that “medical tourism is promoted much more heavily in the United Kingdom than in the United States”.[8]

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 a million and a half 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.[9]

A large draw to medical travel is convenience and speed. Countries that operate public health-care systems are often so taxed that it can take considerable time to get non-urgent medical care. 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.[10] 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.[11]

Additionally, patients are finding that insurance either does not cover orthopedic surgery (such as knee/hip replacement) or imposes unreasonable restrictions on the choice of the facility, surgeon, or prosthetics to be used. Medical tourism for knee/hip replacements has emerged as one of the more widely accepted procedures because of the lower cost and minimal difficulties associated with the traveling to/from the surgery. Colombia provides a knee replacement for about ,000 USD, including all associated fees, such as FDA-approved prosthetics and hospital stay-over expenses. However, many clinics quote prices that are not all inclusive and include only the surgeon fees associated with the procedure.[12]

According to an article by the University of Delaware publication, UDaily:

”
The cost of surgery in India, Thailand or South Africa can be one-tenth of what it is in the United States or Western Europe, and sometimes even less. A heart-valve replacement that would cost 0,000 or more in the US, for example, goes for ,000 in India–and that includes round-trip airfare and a brief vacation package. Similarly, a metal-free dental bridge worth ,500 in the US costs 0 in India, a knee replacement in Thailand with six days of physical therapy costs about one-fifth of what it would in the States, and Lasik eye surgery worth ,700 in the US is available in many other countries for only 0. Cosmetic surgery savings are even greater: A full facelift that would cost ,000 in the US runs about ,250 in South Africa.[12]
”

Popular medical travel worldwide destinations include: Argentina, Brunei, Cuba, Colombia, Costa Rica, Hong Kong, Hungary, India, Jordan, Lithuania, Malaysia, The Philippines, Singapore, South Africa, Thailand, and recently, Saudi Arabia, UAE, South Korea, Tunisia and New Zealand.[3]

Popular cosmetic surgery travel destinations include: Argentina, Bolivia, Brazil, Colombia, Costa Rica, Cuba, Mexico and Turkey. In South America, countries such as Argentina, Bolivia, Brazil and Colombia lead on plastic surgery medical skills relying on their experienced plastic surgeons. In Bolivia and Colombia, plastic surgery has also become quite common. 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. Colombia also provides advanced care in cardiovascular and transplant surgery.

In Europe Belgium, Poland and Slovakia are also breaking into the business. South Africa is taking the term “medical tourism” very literally by promoting their “medical safaris”.[13]

A specialized subset of medical tourism is reproductive tourism and reproductive outsourcing,[14] which is the practice of traveling abroad to undergo in-vitro fertilization, surrogate pregnancy and other assisted reproductive technology treatments including freezing embryos for retro-production.[15]

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 to unite potential medical tourists with provider hospitals and other organisations. Companies are beginning to offer global health care options that will enable North American and European patients to access world health care at a fraction of the cost of domestic care. Companies that focus on medical value travel typically provide nurse case managers to assist patients with pre- and post-travel medical issues. They also help provide resources for follow-up care upon the patient’s return.

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 medical doctors 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

Because standards are important when it comes to health care, there are parallel issues around medical tourism, international healthcare accreditation, evidence-based medicine and quality assurance.

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 best known accreditation group is the Joint Commission International (JCI). They have been inspecting and accrediting health care facilities and hospitals outside of the United States since 1999.[16] Many international hospitals today see obtaining international accreditation as a way to attract American patients.[17]

Joint Commission International is a relative of the Joint Commission in the United States. Both are 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.[18]

In the UK and Hong Kong, the Trent International Accreditation Scheme is a key player. 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.[19] A forecast by Deloitte Consulting regarding medical tourism published in August 2008 noted the value of accreditation in ensuring quality of healthcare and specifically mentioned JCI, ISQUA and Trent.[8]

Increasingly, some hospitals are looking towards dual international accreditation, perhaps having both JCI to cover potential US clientele, Trent for potential British and European 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.[20]

Other organizations providing contributions to quality practices include:

The Society for International Healthcare Accreditation (SOFIHA), a free-to-join group providing a forum for discussion and for the sharing of ideas and good practice by providers of international healthcare accreditation and users of the same. The primary role of this organisation is to promote a safe hospital environment for patients.[21]
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.[22]
References
^ Shaywitz, D.A., & Ausiello, D.A. (2002). Global Health: A Chance for Western Physicians to Give – and Receive. The American Journal of Medicine, 113, 354-357.
^ Bezruchka, S. (2000). Medical Tourism as Medical Harm to the Third World: Why? For Whom? Wilderness and Environmental Medicine, 11, 77-78.
^ a b c d Gahlinger, PM. The Medical Tourism Travel Guide: Your Complete Reference to Top-Quality, Low-Cost Dental, Cosmetic, Medical Care & Surgery Overseas. Sunrise River Press, 2008
^ Roberts, M. (2006). Duffle Bag Medicine. Journal of the American Medical Association, 295, 1491-1492.
^ a b Pinto, A.D., & Upshur, R.E.G. (2009). Global Health Ethics for Students. Developing World Bioethics, 9, 1-10.
^ James, D. (1999). Going Global. The New Physician, 48, online. Accessed 7 May 2009. [1].
^ a b Laurie Goering, “For big surgery, Delhi is dealing,” The Chicago Tribune, March 28, 2008
^ Lagace, Martha “The Rise of Medical Tourism”, Harvard Business School Working Knowledge, December 17, 2007. Accessed July 1, 2008.
^ Linda A. Johnson, “Americans look abroad to save on health care: Medical tourism could jump tenfold in next decade,” The San Francisco Chronicle, August 3, 2008
^ The Private Cost of Public Queues in 2005, Fraser Institute
^ Wait times shorter for some medical procedures: report., Canwest News Service
^ a b “Medical tourism growing worldwide” by Becca Hutchinson, UDaily, July 25, 2005, retrieved September 5, 2006
^ “Medical tourism: Need surgery, will travel” CBC News Online, June 18, 2004, retrieved September 5, 2006
^ Jones CA, Keith LG. Medical tourism and reproductive outsourcing: the dawning of a new paradigm for healthcare. Int J Fertil Womens Med, 2006;51:251-255
^ Jones C, “Ethical and legal conundrums of post-modern procreation” Int J Gynaecol Obstet Dec 4, 2007
^ “Medical Tourism Industry Certifications and Information”
^ “Medical Tourism Magazine”, Medical Tourism Association, February 2008
^ http://www.jointcommission.org/AboutUs/Fact_Sheets/jci_facts.htm
^ “INDIA: Accreditation a must”, International Medical Travel Journal
^ http://www.worldhospitalmonitor.com
^ SOFIHA – Welcome to SOFIHA
^ United Kingdom Accreditation Forum

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