Medical tourism, also referred to as medical travel, health tourism, medical outsourcing, or global healthcare, is defined as seeking medical care outside one's country of residence. This care may include medical treatments, diagnostic or surgical procedures, or dental care.
While patients also purchase pharmaceuticals and medical devices in foreign countries, either via the Internet or in person, this isn't included in the strict definition of medical tourism and won't be discussed in this article.
What's the scope and scale?
In the past many people traveled to the United States and highly developed European countries seeking quality medical care that wasn't available in their own country. However, for a variety of reasons, this movement of patients now flows both ways, with many people traveling to lesser-developed countries for affordable, high-quality care.
Although it's difficult to find accurate data, there's general agreement that the number of Americans seeking medical care abroad is growing. Estimates from several surveys indicate "as many as 2 million Americans went abroad for healthcare in 2008, with forecasts of 6 million for 2010."1 The value of this foreign-purchased care is estimated to be in the billions of dollars.1 Bumrungrad Hospital in Bangkok, Thailand, reported a 30% increase in American patients in 2005, bringing the total to 55,000. Of these individuals, more than 80% had noncosmetic treatments.2
This trend in medical tourism isn't limited to American patients who lack health insurance and are enticed to foreign countries by lower prices. People from countries with national healthcare systems that experience lengthy queues also travel abroad for healthcare. Various factors will continue to influence medical tourism, including the changing economy, resource availability, and quality of services provided.1
For people in the United States covered by health insurance, their familiarity with the concept of medical tourism may be limited to popular books such as the medical thriller Foreign Body by Robin Cook and nonfiction books such as Larry's Kidney and State of the Heart: A Medical Tourist's True Story of Lifesaving Surgery in India.3–5 An article in Time magazine in 2006, "Outsourcing Your Heart," was one of the first references to medical tourism in the popular press.2
Available services?
The services offered to the medical tourist range from simple, elective cosmetic procedures to complicated, lifesaving cardiac surgeries. Especially popular are orthopedic procedures such as total knee and hip replacements. While the typical image of a medical tourist may be a privacy-seeking wealthy celebrity abroad for an image-boosting surgery, the reality is evolving into middle-class Americans seeking medically necessary treatments.6 The Medical Tourism Association, which, according to its website, is an international nonprofit organization, lists comparative cost for nine countries for the following surgeries: heart bypass, angioplasty, heart valve replacement, hip replacement, hip resurfacing, knee replacement, spinal fusion, dental implant, adjustable gastric band, breast implants, rhinoplasty, face lift, and hysterectomy.7 The association further indicates that cancer procedures, neurosurgery, and kidney and liver transplants are available to the medical tourist.
Why do it?
Various reasons compel a person to travel abroad for medical care. These include lower cost, eliminating long waits for elective surgery, privacy, undergoing a procedure that's illegal in the country of residence (such as abortion), or for a procedure that's not yet approved at home. Affordability is a major factor influencing American travelers.1 Rising healthcare costs, coupled with the high cost of health insurance, are causing many Americans to seek alternative options. For more than 40 million Americans who lack health insurance, there's no doubt that lower cost is the driving factor.
Although, for many years, inadequate resources in the host country were the reason people decided to seek healthcare abroad, other reasons exist. In countries with rationing by national healthcare systems, there are considerable wait times for many procedures, both elective and medically necessary. Traveling to another country allows patients to have the procedure significantly earlier than they would've been able to in their own country. Sometimes this can be a matter of convenience, whereas in other cases it may be a matter of survival. Additionally, there are some procedures not readily available in particular countries, such as stem cell therapy or hip resurfacing, so travel abroad may be the only access patients have to these therapies.8,9 Finally, travel abroad can be an attractive alternative, considering procedures with issues of privacy and confidentiality such as aesthetic surgeries, drug or alcohol rehabilitation, or hospitalization for mental illness.
Costs and resources?
Although there's significant cost savings associated with receiving medical services abroad, the cost varies depending on the location. Procedures particularly promoted by foreign facilities include coronary bypass grafts, joint replacements, bariatric surgery, and aesthetic procedures. Popular host countries for these procedures include India, Thailand, Colombia, Singapore, and Korea. Border towns in Mexico, especially Nuevo Progreso and Los Algodones, are well known for their dental care by American snowbirds wintering in Texas and Arizona. According to the Medical Tourism Association, a coronary bypass that costs approximately $144,000 in the United States costs: $8,500 in India; $10,000 in Jordan; $24,000 in Thailand; and $25,000 in Costa Rica.7
Multiple sources offer information regarding medical tourism, including thousands of websites. Forgione and Smith conducted an Internet search using the term "medical tourism," which produced 695,000 Google hits in 0.09 seconds.10 In January 2010, an Internet search on Google revealed 29,100,000 hits for medical tourism in 0.11 seconds. Some of these websites include: http://www.medicaltourism.com, http://www.indUShealth.com, http://www.medicaltourismassociation.com, http://medicaltourismguide.org, http://www.medretreat.com, and http://www.discovermedicaltourism.com. Many of these websites promise to facilitate the procedure from start to finish. They offer instant quotes, physician finding services, and some even offer a guarantee to refund deposited monies if the surgery is cancelled.
What's the global impact?
Expenditures for healthcare in the United States amounted to $2.1 trillion in 2006, which is 16% of the gross domestic product (GDP).11 This translates to $7,026 per capita annually. Government economists are projecting that U.S. healthcare expenditures will almost double from approximately $2.2 trillion in 2007 to $4.3 trillion in 2017. This is projected to be almost 20% of the GDP. The United States currently accounts for almost half of the amount spent globally on healthcare on an annual basis.12
Patient outcomes don't place the United States above other developed nations. Although the per capita costs for U.S. healthcare are roughly double that of Japan, Japan consistently has lower infant mortality and a longer life span. By almost all measures, the United States doesn't find itself at the top of the list. Factors that contribute to the high per capita cost in the United States include treatment decisions made without regard to cost because of insurance, the high use of technology, salaries of healthcare professionals, malpractice insurance, insurance and pharmaceutical company profits, high cost for prescription drugs, and extensive use of prescription drugs.11–13
Developing countries that target medical tourists may have a two-tier system. Tourists are provided with modern, private hospitals staffed by U.S.- or European-trained physicians, many of whom are U.S. board certified. In contrast, public hospitals often lack even the basics. Without the foreign-oriented hospitals in their own country, many of the U.S.- and European-trained physicians may have chosen to leave their native country permanently. However, others may have chosen to work within the public health system and helped to improve the care of the people of their country. This internal brain drain has the potential to perpetuate substandard care for the population.
For foreign countries that have a significant medical tourism business, the impact on the national economy can be positive because of the inflow of foreign currency. In India the national health policy explicitly seeks to "encourage the supply of services to patients of foreign origin on payment."13 Government tax incentives have been available for hospitals catering to this sector of the healthcare market.
As yet, medical tourism has had a limited impact on U.S. hospitals. While the amount spent on care outside of the United States is likely to be in billions of dollars, it's still just a very small percentage of the total U.S. healthcare expenditure.1 Some of this money wouldn't be spent if the patient had to pay the cost in the United States because the uninsured would probably forego elective procedures. In particular, cosmetic surgical procedures may not be undertaken if there was no opportunity to receive the discounted foreign price.
Foreign physicians choosing to return home to work for hospitals that cater to medical tourists may also impact the U.S. healthcare system. Companies such as Wockhardt Hospitals Group, which is affiliated with Harvard Medical International, actively recruit Indian doctors to return home to work in their family of hospitals.9
As countries other than the United States develop modern private hospitals for the medical tourism trade, the impact on U.S. hospitals will be exacerbated by the decrease in foreign nationals seeking care in the United States In addition to proximity, cultural similarities may make them feel more welcome. Major tertiary care centers such as Mayo Clinic, Cleveland Clinic, and Massachusetts General Hospital may feel the impact, as their foreign clientele discover they have more options that are equal in quality and lower in cost.
The current global economic situation may also impact medical tourism. As currencies are revalued against the U.S. dollar, one country may develop an advantage over another.
Are foreign facilities accredited?
Potential medical tourists, faced with the plethora of websites for foreign medical care, can easily become overwhelmed with the choices. One major concern is how to determine if the facility is capable of performing the procedures it advertises, and whether the care will be high quality. In the United States, the gold standard is accreditation by The Joint Commission. Foreign hospitals have similar opportunities to establish their credibility by obtaining accreditation from either Joint Commission International (JCI) or the Australian Council on Healthcare Standards International (ACHSI). JCI has been accrediting non-U.S. hospitals since 1999 and now reports that it has accredited more than 300 healthcare organizations in 39 countries.14 The ACHSI has been accrediting healthcare organizations outside of Australia since 2005.15
The biggest concern of most medical tourists is complications, particularly those that result from malpractice or negligence. Because the legal remedies for malpractice in other countries are usually lacking, some companies now offer a medical liability policy. This may include coverage for medical complications while overseas or after the patient returns home, as well as medical evacuation coverage or trip cancellation for patients unable to proceed with their plans.
A viable option?
Expected to continue growing significantly, medical tourism can be a threat or an opportunity to U.S. healthcare. American hospitals can develop agreements with accredited foreign hospitals to provide them with technology and expertise as well as opportunities for advanced education for foreign physicians. For the foreign hospital, affiliation with an American hospital may increase its credibility to the potential medical tourist.
For U.S. patients, the most common reason for seeking care in foreign hospitals is lower cost. As this trend continues, nurses can expect to receive requests for information and opinions regarding patient options for care abroad.
A world-class hospital?
Bumrungrad Hospital in Bangkok, Thailand, is one example of a private hospital that's developed international clientele. Opened in 1980 as a 200-bed facility, it currently offers 538 inpatient beds, including 37 ICU and 14 CCU beds. Other facilities include 19 operating theaters, interventional radiology, MRI, PET, and CT scanners. Bumrungrad has been accredited by Joint Commission International since 2002, the first hospital in Asia to meet that standard.
The hospital has been publically traded on the Thailand Stock Exchange for more than 20 years. It has international representative offices in 24 countries, and over 100 interpreters on site. The hospital's management team is American-led and comprised of more than 3,000 employees, with over 1,000 physicians and dentists and 900 nurses.1 Of these physicians, more than 200 are U.S. board certified.2 Over 1.1 million patients are treated annually in the facility's inpatient and outpatient centers; approximately 407,000 are international patients from 190 different countries.1
Bumrungrad's website provides "real cost information," which is information based on actual invoices patients paid upon leaving the hospital. The amount is all-inclusive—reflecting surgical fees, physicians' fees, lab tests, medicine, and room fees—the total inpatient or outpatient bill for the procedure. For more than 40 procedures, the facility publishes the median cost and the range for the middle 50%. For example, total knee replacement has a range from $12,542 to $14,719 for half of all cases based on 2009 data, with a median of $13,364.3
