Is Medical Tourism the Answer to Our Unaffordable Health-Care System in the United States?

by Fiona Weeks

Medical Tourism in the News

Medical tourism has hit the news recently, with features in the U.S. News and World Report, the New Yorker, the Economist, and most recently, the Sunday New York Times.⁸ Not only are health-care professionals aware of medical tourism, but also the general population is getting a taste of how appealing an option it just might be. A comments forum on the online version of the New York Times story “In Need of a New Hip, but Priced Out of the U.S.” allowed readers to share their experiences of and thoughts on medical tourism. This “technoethnography” offers a critical ethnographic look into medical tourism. Sprinkled through this article are New York Times readers’ comments on different aspects of medical tourism.

What Is Medical Tourism?

For years, people have ventured beyond the borders of their home countries in a process that has become popularly known as medical tourism.⁷ Although traveling for health and wellness purposes is no new phenomenon, it has developed quite drastically over time. Egyptians and Greeks traveling to baths and natural hot springs may have been the earliest medical tourists, and as early as the 18th and 19th centuries, Europeans and Americans traveled far and wide to seek out remotes spas and healing centers; but things are changing. Natural healing spas such as the beer baths in Karlovy Vary, Czech Republic, are still popular tourist destinations; but people are also traveling abroad to seek out surgical centers for more serious, emergent conditions. Rising health-care costs in the 1980s and 1990s, paired with increased globalization and ease of travel, have combined to create a boom in the medical tourism industry. And yes, medical tourism is now an industry. It is estimated by medical tourism experts that at least 150,000 US citizens went abroad for medical treatment in 2006, and as many as 6 million in 2010. The trend line projects even greater numbers in the coming years as patients struggle to seek out quality care at an affordable price. Basic economics is forcing health care to operate in competitive markets, and we are starting to see how these changes in health-care consumption are playing out.

Why the Demand for Medical Tourism?

⁴

I would travel to another country for a joint replacement or for any other kind of surgery.

The lobbying groups that manage to keep laws in place that perpetuate their own greed need to be silenced. The government needs to stop taking their money as contributions to their re-election campaign funds and do what they are paid to do

– and that is serve the peoples interests, not their own and certainly not the interests of big business. – Anonymous ⁶

So why is health care so much more expensive in the US? Institutions and existing, frozen structures in the US health-care system are at the root of this problem. Unlike other countries, where, according to the National Center for Policy Analysis, “labor costs are lower, third parties (insurance and government) are less involved or not at all involved, package pricing with price transparency is normal, there are fewer attempts to shift the cost of charity care to paying patients, there are fewer regulations limiting collaborative arrangements between health care facilities and physicians, and malpractice litigation costs are lower,” the US suffers from these exact inefficiencies in the health-care system which significantly drive up the cost of treatment.⁴ The cost of actual implants and devices are also exceptionally high in the US, and there’s a reason for it. “In the United States, nearly all hip and knee implants – sterilized pieces of tooled metal, plastic or ceramics – are made by five companies, which some economists describe as a cartel.”⁸ The FDA keeps out generic and foreign-made implants, and trade barriers disrupt the existence of what would otherwise be a globally competitive market for medical devices. “Health care has been insulated from the forces of globalization. This has been great for hospitals and doctors, but worse for consumers. It’s one reason that the cost of health care has risen so much faster than that of almost everything else.”⁹ “If domestic hospitals actually had to compete with places like Bumrungrad or CIMA, the way American car companies have to compete with Toyota and Honda, they might be forced to become more efficient.”⁹ In essence, the US used to be able to get away with outrageously high prices because it was considered the best, and when someone’s life is at risk, those who are able are often willing to pay incredibly high amounts for the best doctors and the best care. But with other nations quickly developing and modernizing, the US is no longer the only country in the world with respectable health-care options. In fact, some would argue that other countries have surpassed the US in terms of medical excellence. Though medical tourism has its flaws, for some it is the only option for accessing care. Furthermore, wealthy medical tourists can enjoy a lovely vacation in combination with their medical treatment. Disruptive innovation will always result in winners and losers, but if the disruptive innovation of medical tourism and the globalization of health care spurs US hospitals and insurance companies to operate at more financially feasible levels for the average US citizen, then consumers will likely respond to the price and seek medical treatments where they are effective, affordable, and close to home for convenience reasons. Until then, Americans’ spending of medical money abroad might just save them money and help control medical costs in the US.⁹

Are There Different Kinds of Medical Tourism?

^1,2

I would not hesitate to travel to another country if it provided the level of care such as in Belgium, Switzerland, Germany, etc. My father traveled to another country for treatment of his cancer in 1960s;

the therapies were not ‘legal’ in the US; he survived until 2010, working and living well, into his mid-nineties

.” – Anonymous ⁶

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There are three broad categories of medical tourism from a legal perspective. The first type is characterized by operations such as hip replacements and cardiac bypass surgeries that are legal in both the home and destination countries of the patient. Financial motivations often drive a patient to pursue treatments such as these abroad. The second type of medical tourism is characterized by services such as abortion, assisted suicide, stem cell treatment and reproductive technologies that are legal in some countries but not others. Patients pursuing these operations are often participating in medical tourism for lack of access or availability of treatment in their home country. The third type involves people participating in surgeries and procedures, such as organ sales, that are illegal in both the home and destination country. Medical tourism for illegal procedures is operated on a black market. Though the intent is varied based on cost and availability, these three types of medical tourism illustrate the “ways” and “whys” of medical tourism as it is understood today.

Who Participates in Medical Tourism?

²

I was in an automobile accident in Canada and needed surgery on my leg with full anesthesia and six days hospitalization

. I did not have insurance at the time.

Cost to me and my family: $250. I was playing competitive soccer six weeks later. – Anonymous ⁶

The reasons for participating in medical tourism are as numerous and varied as the types of medical services being sought abroad. In short, there are many. As evidenced by the above quote, medical tourism is sometimes even unplanned. Other medical tourists leave the US because they are uninsured, and seeking treatment abroad is substantially cheaper. These patients are generally paying for their services out-of-pocket and while not always uninsured, are generally at least underinsured and have limited economic resources to put towards health costs. Another wave of medical tourists go abroad because they are prompted by their insurers to do so. Some insurance companies offer rebates, waived deductibles, or other payment incentives for patients who choose to undergo operations abroad. The cost for insurance companies to send their subscribers abroad is much less than paying for care here in the US, and the patients are often treated to more luxurious accommodations, private nursing, and tourist activities as well. Public discussions today even include proposals to incentivize Medicare and Medicaid patients to relieve stress on the US health-care system by accessing care abroad. Finally, there has always been a population of immigrants and minorities who have preferred to go home to trusted doctors, and that continues to be motivation for some medical tourists.

Who Helps Facilitate Medical Tourism?

⁵

I have a second home in Thailand and do most of my medical work at

Bumrungrad Hospital in Bangkok which is a US Accredited hospital.

The prices are substantially cheaper – and the results are fantastic. – Anonymous ⁶

Hospital accreditation programs and medical tourism companies have sprung up in light of the growing popularity of medical tourism. Groups such as the Joint Commission International (JCI) certify that hospitals abroad meet desired standards. The JCI is a sub branch of the Joint Commission (JC) that is the largest accreditor of hospitals and health-care organizations in the US. The JCI stamp of approval, as one might call it, helps guide a patient’s decision of where to pursue treatment. Although there is a literal cost associated with becoming accredited by the JCI (or other similar approval organizations) that prohibits some hospitals from being certified, especially in developing countries, the consistency across continents and national borders have bridged a noteworthy gap between the US and other countries. Accreditation programs are ways that patients can inform themselves of trustworthy places to travel abroad for medical tourism, without having to do a lot of personal research. It also assists patients in remedying the asymmetry of information problem frequently encountered when making less than perfectly informed medical decisions. In addition, a new sort of travel agent has emerged as a result of rising medical tourism demands. Groups such as the Medical Tourism Corporation offer services to guide medical tourists through the hoops and hurdles that come along with venturing outside the US for health care. Medical Tourism travel agents negotiate with insurance companies, help patients identify the best hospitals for their specific surgeries, sometimes offer free cost estimates, and even coordinate the patients travel and stay in the destination country. These services, along with the JCI, have helped ease the process of medical tourism. The JCI surveyors, who are themselves medical professionals, perform unannounced check-ins on accredited hospitals around the world to ensure that the standards consistently meet compliance measures. The JCI takes into account cultural factors, such as legal systems and prevalent religions of a country, when designing the accreditation process.

Patterns in Medical Tourism

⁷

I would most certainly travel for better and less expensive care.

We don’t have the best health care system, just the most expensive one

, and it doesn’t provide better health outcomes than foreign systems. – Larry J ⁶

Medical tourism has occurred in three distinct fashions for many years. Medical tourism in the US grew in the late 1900s when health-care costs started to increase drastically. Shocked by the bills that they were receiving after even an insured trip to the dentist, patients started looking elsewhere. “Tooth tourism” became a popular phrase as patients left the US and flew to countries such Mexico or Costa Rica to have dental procedures performed that were not covered by insurance. Meanwhile, elites from developing countries who could afford to do so flew to the US to receive (what was revered to be) the best medical treatment in the world. Also, US citizens flew abroad for elective procedures such as Botox and other cosmetic surgery ventures, since they are rarely covered by insurance and are more affordable abroad. Although for years patterns were stable, they are now being shaken. Big changes have occurred in the US in the last few decades, and not only is there global competition for the quality of care available to people, patients are taking control of their own financial security in regards to health care and seeking not only quality, but cost effective treatments. The combination of affordability and quality is increasingly available … just not in the US. Patients of all socioeconomic classes are traveling abroad for surgeries to both developed and developing countries. Top-quality care is available in more places than the US, and Americans are increasingly taking advantage of this. Countries have even gained reputations for specializing in certain procedures.

Benefits of Going Abroad

¹⁰

My husband had eight dental implants done in Los Algodones, just over the border, 7 miles from Yuma, AZ, for a

total cost of $9200 vs $44,000

here in the Seattle, WA area. State of the art equipment and dentists licensed in both AZ and Mexico. Even with the cost of two trips, rental cars, and motels

, it was less than one fourth the cost of having it done here

. Crowns are $200, and I had an extraction and xrays for $60

.

I cannot speak more highly of the entire experience–it was flawless. – Anonymous ⁶

Affordability plays a huge role in people’s decisions to go abroad for medical procedures. To compare a few costs, the Washington Post presented data from 2012 highlighting discrepancies in health-care costs between the US and other countries. To reiterate, the difference between getting an angiogram in Canada ($35) and the US ($798) is $763. In terms of higher-cost procedures, the difference between an appendectomy in India ($254) and the US ($13,000) is $12,746. Even higher-cost procedures such as a coronary artery bypass show cost differences as great as $63,060, with the procedure being available in India for $4,525 and the US for $67,585. For price-conscious Americans and especially those without insurance, traveling abroad for medical procedures makes more sense financially. And for some, if they want or need to have the procedure done, going abroad is the only feasible option.

Accessing Care Abroad

I am in so much pain and

can’t wait a year until my insurance will let me

have surgery

and then they still won’t compensate me much. I would be interested in going and if I was sure of the facts that it was a trustworthy alternative, I would pack my bags tomorrow. – Carol Smith⁶

Medical tourism also gives patients greater access to health care. Whether access is looked at in terms of less waiting time, ability to pay, or receiving treatments that are illegal in the home country, by leaving the country the patient is able to receive care they otherwise could not acquire in the US. “The growing numbers of uninsured and underinsured people in the United States … mean that many have little choice but to travel for affordable essential health care.”¹¹ While the significantly lower costs of procedures abroad are enticing, it is important to be aware of potential complications.

Drawbacks of Going Abroad

¹¹

For all the people who said they would travel to a foreign country for surgery, have they thought about what they would do if they have a

complication after they get home

? What if they need to be re-operated on? How easy do they think it will be to find a surgeon who is willing to fix another surgeon’s mess? – Anonymous⁶

While some insurance companies are beginning to cover medical tourism ventures, it is certainly not a part of all medical insurance plans. Also, just because the initial cost of medical procedures abroad is lower does not also necessarily mean there will be no additional costs. Complications that arise during or after surgery are generally just as likely outside the US, and in some cases even more likely, due to less stringent regulations. While the US system for medical malpractice drastically inflates the cost of health care in the US, it is a form of insurance for both patients and doctors. Insurance policies in the US also assist patients with dealing with unexpected costs due to surgical complications. Deciding to go abroad for medical procedures because of a lack of insurance does not insure you against this risk factor. Complications can and do arise, and sometimes dealing with them in a foreign country where you do not have residence is more difficult than in the US. Access to local justice systems, representation in local justice systems, and the time frame with which errors could be dealt with are not always conducive to great outcomes for the patient. Alternatively, if problems occur when the patient is back in the US, insurance companies do not generally want to pay for cleaning up a foreign surgeon’s mistake. It is expensive for insurance companies to cover the cost (or even partial cost) of treatments; not only patients are price conscious. In some cases, patients may have to travel back to the destination country for follow up assistance due to unexpected complications if their physician in the US is unwilling or unable to provide the necessary service. To counteract this occurrence and unexpected cost for the patient, “some providers include treatment for complications in their package price.”⁴ Though more minimally discussed, “another key issue with respect to medical and health tourism is its potential biosecurity risks with respect to humans acting as vectors for disease and drug-resistant bacteria.”³ Ethical issues also arise when privacy measures are introduced. Should patients who receive treatment abroad and pay for it out of their own pocket have to disclose that information to their insurers?

The Political Economy of Medical Tourism

¹¹

I wish I was aware of this option either time I had my hips done in the last two years. The whole thing is such a racket.

The doctors and hospitals are getting rich and the patients are the ones who suffer-not only with pain and suffering but with their wallets being drained as well

. Maybe one day when a congressman or senator can’t afford their joint replacement, something will be done. But I doubt it. – Anonymous ⁶

We have globalization of everything now, why not global health care. And the insurance companies should promote that concept for their own bottom line. But

alas the republicans will block it with a virtual filibuster

, many Republican state legislatures won’t even allow insurance exchanges. – Roland ⁶

The political economy of medical travel is largely concerned with the ways in which medical services and devices are being traded across borders and the legislation that is affecting these transactions. At the outset, increased globalization, relatively peaceful political relations and affordable travel is encouraging and allowing the flow of people across borders for recreational and medical purposes. “Many countries have porous borders facilitating the movement of patients for health services…changing demographic profile of aging populations in high- and middle-income countries seeking health care, the ease of international travel and global communication, the retreat of neoliberal states from the provision of public services, and the increasing port ability of health insurance” all lend themselves to increased medical tourism.¹¹ The state of health care in the US is unaffordable for many, and “if Obamacare is overturned, forty million Americans without insurance will stay that way.”⁹ Employees who currently rely on health insurance through their employers will also be in sticky situations. If health-care costs continue to rise at the current rate it will become impossible for even large companies to finance such expensive insurance plans for their employees, and “fewer employers will offer health insurance.”⁹

The ‘Tourism’ of Medical Tourism

¹¹

One of the perennially

struggling airlines could make a lot of mone

y by just setting aside a few flights a day for medical tourists. Make arrangements with overseas hospitals and insurance companies, put a doctor and a few nurses on board instead of stewardesses, then charge a big premium for putting it all together. – Anonymous⁶

International treaties and agreements also affect the political economy of medical tourism. The WTO, UN Conference on Trade and Development, and GATS have provided the “the legal framework for the liberalization of the international trade in health services.”¹¹ The involvement of the JCI is another example of ways that the political economy has evolved within medical tourism. Health insurance plans that are tied to international hospitals accredited by the JCI and other global constituencies that aim to assist hospitals in developing countries pass inspections for accreditations are increasingly popular. As previously mentioned, medical tourism travel agents also engage in the political economy of medical tourism. Along with assisting in the logistics of traveling to the destination country, these facilitation companies offer translation services, suggest hotels to stay in, and set patients up with tours and fully booked vacation packages to combine entertainment and pleasure with medical services. And as suggested by the above quote, there is still room for growth in the medical tourism world. Medical tourism can stimulate the economies of destination countries, but there are negative implications to medical tourism in developing countries as well.

Anthropological Impact

The anthropological impact of medical tourism is extremely complex.¹¹ There are benefits to highlight and also negative implications that severely disrupt the local health system. On one hand, developing medical communities and enterprises in rural communities and underresourced areas bring foreign money to stimulate the economy. Specialized health-care facilities intended for foreigners have the potential to create jobs and also increase access to health care for the local population, especially from medical specialists. The creation of health-care facilities also has the potential to induce irreparable harm to the existing health-care system in cases “where elite technologically sophisticated hospitals catering for wealthy foreign clients stand beside poorly resourced public hospitals.”¹¹ Even though hospitals take on a certain number of charity cases from the local population to help justify the creation of the specialized center for medical tourists, health becomes stratified and “wealthier mobile patients utilize the health care resources of low-income countries at the expense of local patients.”¹¹ The creation of private, medical tourist centered hospitals also exacerbates the “brain drain” issue, as highly skilled physicians end up working in the private sector, rather than in public health services where locals access health care. It is critical that health policies are created and implemented to protect the vulnerable populations that are adversely affected by medical tourism.

Conclusions

Going back to the beginning, I’ll ask again, is medical tourism the answer to our unaffordable health-care system in the US? Who knows. But I’ll venture to say that it may be a piece of the puzzle. “Unless we find some other way to rein in health-care costs, the logic of free trade in medicine is going to become harder to resist.”⁹

If medical tourism provides greater access to health care, and living in a state of health is either a fundamental right or just something worth pursuing individually, then medical tourism may be the answer. We live in a globalized world. Our shoes, clothes, cars, and technology come to us from halfway around the world. Why not travel halfway around the world for our health? But before you go, keep in mind one last thing: Although medical tourism is a booming business and a rational solution that allows the free market to compete globally, different countries remain unique; and despite their economic union, one caveat remains: you may return with a parasite indigenous to that country; so while abroad, “Don’t drink the water!”

Notes

1. Cohen G. How to regulate medical tourism (and why it matters for bioethics). Dev World Bioeth. 2012 Apr;12(1):9–20. doi: 10.1111/j.1471-8847.2012.00317.x.

2. Cohen G. Protecting patients with passports: medical tourism and the patient protective-argument. Iowa Law Review. June 9, 2010;95(5). Harvard Public Law Working Paper No. 10–08.

3. Hall CM. Health and medical tourism: a kill or cure for global public health? Tourism Rev. 2011;66(1/2):4–15.

4. Herrick DM. Medical Tourism: Global Competition in Health Care. Dallas, TX: National Center for Policy Analysis. November 2007. Epub 24 Aug. 2013. NCPA Policy Report No. 304. Available at http://w.medretreat.com/templates/UserFiles/Documents/Medical%20Tourism%20-%20NCPA%20Report.pdf.

5. JCI (Joint Commission International) – what does it tell about a medical tourism hospital? [blog post]. Medical Tourism Corporation. 24 Aug. 2013. http://www.medicaltourismco.com/medical-tourism/medical-tourism-jci.

6. Comments on: Rosenthal E. In need of a new hip but priced out of the U.S. New York Times. 3 Aug. 2013. Available at http://www.nytimes.com/2013/08/04/health/for-medical-tourists-simple-math.html?_r=2&).

7. Pickert K. A brief history of medical tourism. Time. 25 Nov. 2008. Available at http://www.time.com/time/health/article/0,8599,1861919,00.html.

8. Rosenthal. Op cit.

9. Surowiecki J. Club Med. New Yorker. 16 Apr. 2012. Available at http://www.newyorker.com/talk/financial/2012/04/16/120416ta_talk_surowiecki.

10. The high cost of medical procedures in the U.S. Washington Post. 2 Mar. 2012. Available at http://www.washingtonpost.com/wp-srv/special/business/high-cost-of-medical-procedures-in-the-us.

11. Whittaker A, Manderson L, Cartwright E. Patients without borders: understanding medical travel. Med Anthropol. October 2010;29(4):336–343.