Medical Tourism

Scott Abernethy

MEDICAL TOURISM + Its Effect on Public Health

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Contents

Contents 01. Introduction

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02. Regulation + Policy

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03. Public Health

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04. Conclusion

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05. References

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Introduction

Introduction

01 Cleveland Clinic // Abu Dhabi, U.A.E. HDR, Inc.

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Introduction

Introduction Introduction The emerging popularity of medical tourism emphasizes a number of contemporary themes in the provision of health services. These include “the privatization of healthcare in postindustrial economies, the growing dependence on technology, uneven access to health resources, the accelerated globalization of healthcare and tourism, rampant consumerism and cherishing the body beautiful” (Connell).

In recent years, medical tourism has grown as a result of institutional transformations in medical care, global access to health, and new attitudes to personal identity and medical care, enabled by developments in international communication and transportation.

Medical tourism is ultimately grounded in diverse political, economic, social and cultural influences.

Medical tourism has also “emerged from a greater willingness to accept alternative practices and procedures, and experience different cultures and places, even though most medical tourism is centered on ‘formal’ biomedical procedures. It has, however, followed various social and economic changes encouraging a more holistic approach to health care where health-seeking behavior has become more likely to reflect the views of patients in terms of their own values, beliefs and philosophical orientations towards health and life, rather than those of the ‘medical establishment’” (Connell).

The search for relief of suffering and cure of illness or injury has historically included the possibility of travel dating back to antiquity; natural hot springs, thermal baths, spas, beach resorts and mountain sanatoriums attract travelers in search of treatment.

Some healing pilgrimages have powerful religious dimensions. Of course, “medical brokerages do not promote healing pilgrimages to sacred sites. They bring the search for healing into the era of global capitalism” (Turner).

Medical brokerages offer treatments at destination medical facilities provided two key attributes. First, there must be a significant spread between the price of the procedure in the tourist’s home country and 03

the cost of the procedure in the destination country.

There must be financial justification to travel after taking into account the cost of the procedure, accommodation, travel expenses, etc. Second, the “health problems precipitating travel cannot require emergency medical care” (Turner).

Grounded in political, economic, social and cultural influences, medical tourism will have an enormous impact on medical architecture worldwide. The question becomes, “How do you make the patient and family comfortable for two weeks? Medical tourism’s answer is to include everything you would find in the hospitality industry, such as a five-star hotel, bars, entertainment, and retail: families feel confident that they can care for their relatives and have a vacation at the same time. It’s drawing people in from around the world” (Burkett). Therefore facilities will be required other than just health care facilities; it’s an economic by-product of medical tourism.

In summary, medical tourism is “linked to increased medicalization, healthcare commodification and the desire for instant gratification, which, together with shifts in concentrations of medical expertise and technologies, produce new geographies of hope: Medical tourism reinforces privatization alongside a technological and medicalized view of the health system where medical services can be bought ‘off the shelf ’ from the lowest-cost provider, rather than well-being created by remedying the social, political and economic determinants of health” (Ormond).

The question becomes: What policies should the US push on a global scale to deal with the inevitable growth of medical tourism? We must shift the focus of medical tourism from globalization on an economic front to one that will address issues of worldwide public health: “the science and art of preventing disease, prolonging life and promoting health through the organized efforts and informed choices of society, organizations, public and private communities and individuals” (Hall).

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Introduction

Health Tourism

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Medical Tourism

01. Financial cost Foreign medical services are cheaper than those available in the medical tourist’s home country.

Travel “may also occur within jurisdictions – as in the case of the European Union – as well as domestically as in the case of medical-related mobility in federal systems where there may be different public and private medical services, as well as different funding and insurance mechanisms, between states and provinces” (Hall).

Medical Facility

Nonmedical Facility

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Structure

Medical Tourism vs. Health Tourism This paper defines health tourism as “the organized travel outside one’s local environment for the maintenance, enhancement or restoration of an individual’s wellbeing in mind and body. A subset of this is medical tourism, which is the organized travel outside one’s natural healthcare jurisdiction for the enhancement or restoration of the individual’s health through medical intervention” (Carrera and Bridges). This is an important distinction as medical tourism is a narrower category of study with broader political, social, and ethical dimensions.

Cohen has outlined a fourfold classification of medical tourists: “(1) ‘medicated tourist:’ receives treatment for health problems that occur during an overseas vacation; (2) ‘medical tourist proper:’ visits a country for medical treatment – unrelated to the trip – and who may also decide on a procedure once in a country); (3) ‘vacationing patient:’ visits mainly for medical treatment, but makes incidental use of vacation opportunities, usually during the convalescence period; and (4) ‘mere patient:’ visits solely for medical treatment, and makes no use of vacation opportunities” (Connell).

Five Drivers of Medical Tourism In medical tourism, health services are usually being consumed for at least one of five reasons listed below.

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02. Time cost Medical services may be available internationally in a more timely manner and patients can take advantage of shorter wait lists.

03. Cultural proximity Due to “migration and the demands of a global labour market, expatriates and migrants may return to their country of origin for medical treatment for cultural, family and language reasons” (Hall).

04: Regulatory structures and governance “The absence of regulatory structures in the destination jurisdiction that restrict the availability of a medical service in the generating country can be a significant incentive for engaging in medical tourism in some circumstances” (Hall).

05: Quality The standard of medical services, including patient care may be higher quality than in the tourist’s home country.

Due to the fact that medical tourism is curative in focus as opposed to the preventative scope of health and tourism, trends point toward privatization of healthcare, uneven access to health resources, the accelerated globalization of healthcare, and consumerism. If the “commoditization and marketisation of individual health is acceptable in some jurisdictions then new questions arise as to where the limits of commercialization should lie, and the ethical (and medical) demands of the individual versus the ethical demands of other individual and organizational stakeholders” (Hall). Furthermore, where does public health fit into the emerging model of medical tourism?

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Regulation + Policy

Regulation + Policy

03 Bumrungrad International Hospital // Bangkok, Thailand Design World Partnership

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Regulation + Policy International Trade Agreements Medical tourism is fueled by a global industry facilitating movement of patients to regions where they can receive low-cost health care. “The internet, lowcost telecommunications and economy air travel all facilitate movement in search of affordable health care” (Turner), Due to technological and other developments, health services have increasingly become tradable. Because of their increasing economic importance, “guiding principles and rules for international trade in services have been laid down in a multilateral trade agreement, the General Agreement on Trade in Services (GATS)” (Timmermans). GATS outlines 4 modes of trade in services all of which lend advantages and disadvantages to medical tourism and its effect on public health.

Mode 1: Cross-Border Supply

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With regard to medical services, “cross-border supply mainly takes place in the form of telemedicine, which may provide opportunities to expand sophisticated medical services to relatively remote areas and/or less-developed countries. It can also facilitate the dissemination of knowledge and help upgrade the skills of medical personnel. Thus telemedicine can be a tool to help alleviate shortages of specialized human resources. Yet for telemedicine to be feasible, expensive equipment and a reliable infrastructure are prerequisites; thus funds might get diverted away from the provision of basic health care services to be invested in infrastructure” (Timmermans).

Furthermore, there is a risk that telemedicine services will cater mainly to the urban upper and middle classes, and will attract human resources away from remote areas or from more basic health services.

This is evident in the growing technology divide occurring internationally. Finally, “telemedicine raises complex liability and confidentiality issues, which should be addressed before its large-scale application” (Timmermans).

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Mode 2: Consumption Abroad Mode 2 addresses patients traveling abroad for medical treatment. Some developing countries including India, Singapore, and Thailand are actively seeking to attract paying foreign patients, as a way to earn revenues. In order to successfully attract such patients, “the services offered must be of good quality.

At times this may motivate countries and institutions to upgrade their services and facilities; if so, these improved services obviously may also benefit domestic patients. However, if the upgrading of services for foreigners is funded from the budget for the provision of domestic health care services, questions about equity and efficiency arise” (Timmermans).

One of the largest potential risks at a public health level is the possibility that foreign patients will end up ‘crowding out’ domestic patients, in other words, a two-tier healthcare system develops. Advocates argue that countries may be able to use part of the revenues earned from foreign patients to upgrade domestic health services. Furthermore, “nationals traveling 05.13

Regulation + Policy

abroad to obtain medical services elsewhere might alleviate capacity constraints in domestic health facilities. Treatment abroad could also be a means to reduce costs, or to obtain access to services not available in the home country. But in most developing countries, the cost of medical treatment abroad would have to be paid for by the patients themselves and hence would probably be affordable only for the most affluent patients” (Timmermans).

Mode 3: Commercial Presence Mode 3 mainly relates to foreign direct investment, for example in hospitals and clinics or in health insurance companies. Foreign investment may lead to an increase in quality and may facilitate transfer of technology and knowledge. But it is important to keep in mind that “foreign investors are first and foremost investors; as such, they will look for a return on their investment. Hence, like domestic commercial enterprises, hospitals and insurance schemes with foreign investment will essentially aim to serve those who have the ability to pay, leaving it to the public sector to care for the others. Such ‘cream-skimming’ practices reduce the possibilities for cross-subsidies between wealthy and indigent patients, and thereby may reduce equity. In fact, with regard to commercial presence and foreign investment in health services, the main question is whether commercialization of those services is desired, rather than whether the investment is of foreign origin” (Timmermans).

Again, by catering to the upper classes, advocates for medical tourism argue that foreign commercial investment may free up public resources, which could be redirected to providing services for the poor and disadvantaged. Furthermore, “foreign investment could create employment opportunities, although it may also ‘divert’ health workers away from more remote areas or from more basic services” (Timmermans) Mode 4: Movement of Natural Persons Finally, mode 4 relates to the migration of people in order to work abroad; notably the movement of doc07

tors and nurses to fill vacancies in foreign countries.

The movement of health workers from ‘developing’ countries to ‘developed’ countries can improve economic efficiency. For receiving countries, “the benefit usually takes the form of alleviating shortages of domestic medical personnel— a growing problem in many middle- and high-income countries. For the sending countries, the welfare effects depend crucially on where foreign healthcare workers spend their income” (Arunanondchai and Fink).

Another important question is how the outflow of healthcare workers affects the supply of medical personnel in the sending countries. In the Philippines, the outflow of nurses has so far “not led to any domestic shortages; in contrast, the net outflow of nurses from Indonesia and Malaysia seems to have exacerbated already existing shortages of nurses in the country” (Arunanondchai and Fink).

As outlined in the four modes of trade in services by GATS, each mode poses potential positive and negative effects. While outcomes will be based, first and foremost, on the specific national circumstances and context, the nature of medical tourism in essentially global. In a globalized marketplace, one particular context will obviously affect all others. Overall, the potential benefits of international trade in health services are assumed to come at the expense of equity.

According to the United Nations, health is a human right. In order to respect and carry out this right, important public health objectives must be at the forefront of the rise of medical tourism. Governments must begin to enact regulations in order to mitigate potential negative consequences of trade in health services outlined above.

International Trade Agreements The Joint Commission is a nonprofit organization and the premier accrediting body in health care within the United States. The Joint Commission evaluates and accredits over 19,000 health care organizations and programs in an attempt to improve safety and

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quality of care. According to the Joint Commission, “accreditation provides a visible commitment by an organization to improve the quality of patient care, to ensure a safe environment and to continually work to reduce risks to patients and staff. In order to address the needs of the international community, the Joint Commission established the Joint Commission International. The international accreditation program began in 1999 in order to meet the worldwide interest in quality improvement. The Joint Commission International accreditation standards seek to establish uniform expectations for “structures, processes and outcomes for hospitals.” The Joint Commission International has accredited over 450 hospitals and health care facilities in Europe, Asia, India, the Middle East, South America, and the Caribbean” (Forgione and Smith).

Potential problems with accreditation for the medical tourism destinations include that the commercial aspirations of the accreditation schemes may become ends in themselves as the primary lure in attracting foreign patients. This is evident in the fact that many accreditation schemes operating internationally are private companies or corporations. Many developing countries that are often heavily involved in medical tourism may have “no access to the accreditation process, or engaging in accreditation may lead to financial hardship. There may be a considerable amount of marketing ‘hype’ and manipulation of the accreditation market. Further, accreditation processes may not tackle ethically contentious areas, such as organ trafficking, payment issues around organ and tissue donation, selective gender abortion surrogate pregnancy, unnecessary operations and use of unproven therapies” (Hall).

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Economic and Political Dimensions Globalization is the circulation of goods and services in response to criteria of efficiency. As mentioned previously, trade in health care services is often cited as one of the most rapidly growing markets in the world. The ease of seeking medical treatment and services overseas contributes to the growing worldwide spending on healthcare. The rise in health care spending on a global basis is “supported by the existence of a global market for international hospital chains. The California-based Adventist Health System operates a network of hospitals and clinics in more than 10 developing countries. Bon Secours is another health system with global impact, including facilities in the United States, United Kingdom, France, Ireland, and Peru” (Forgione and Smith).

Governments in India, Thailand, Singapore, Malaysia, the Philippines and Indonesia regard medical tourism as an important resource for economic and social development. In these countries, revenue generated from tourism is a significant part of the national economy and has the potential to contribute to public health care services. Leaders there see “integrating the tourism industry with the health care sector as a progressive vehicle for diversifying their economies, attracting foreign investment, promoting job creation, building the health services industry and using regional strengths to benefit from the doctrine of comparative advantage” (Turner).

Developed nations such as the United States, Canada, and United Kingdom attract physicians and nurses from countries around the world to study and practice. Countries such as Singapore, Malaysia and the Philippines want to counteract this trend by reversing the flow and making the provision of health care a core competency of their national economies.

With additional revenues flowing into hospitals and clinics, “private medical centers can flourish, public hospitals can generate increased revenue and provide better care, salaries will rise and aid retention of staff, professional opportunities will expand, specialization of clinical practice can occur, physicians, nurses

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Supporters of medical tourism state that revenue generated from treating international patients can be used to cross-subsidize publicly funded health care - Leigh Tuner

and other health care providers will be deterred from seeking better career opportunities elsewhere, expensive medical devices will become more affordable, and ‘trickle-down’ effects will travel through the city-state’s economy” (Turner).

Proponents of international medical travel argue that “increased patient volume has the advantage of promoting economies of scale, maximizes institutional efficiencies, and helps hospital chains and government ministries negotiate better contracts with companies selling medical devices, hospital supplies and pharmaceuticals. Advocates of international medical travel argue that increased patient volume generates better clinical outcomes as high volume combined with specialization enables providers to reduce errors in case management. Supporters of medical tourism state that revenue generated from treating international patients can be used to cross-subsidize publicly funded health care. Rather than harming local patients by blocking them from gaining access to services, the expansion of the market for international patients is supposed to lower the overall cost of providing publicly funded and privately purchased medical care to residents of Singapore” (Turner).

Proponents of international medical travel, in both the public and private sector, argue that medical tour-

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ism provides a “long-term economic justification for building infrastructure, encourages economic and social development, permits expansion of the private and public health care sector, complements efforts to promote public health and preventive medicine, and serves the interests of even the poorest members of society by generating additional revenue for the provision of publicly funded health care” (Turner).

Substantial private and public investments are going into upgrading older facilities and building new hospitals and clinics in India, Thailand and Singapore.

The ‘poster child’ for medical tourism and private investment is Bumrungrad International Hospital in Bangkok, Thailand, a 554-bed multi-specialty hospital completed in 1997. The medical staff at Bumrungrad includes over 200 U.S. board-certified physicians that treat over 500,000 international medical tourists every year. Industry leaders and government ministers in a host of nations are attempting to use the “economic doctrine of comparative advantage to ‘export’ health care by ‘importing’ patients into their countries. They are confident that the global health care market for international patients will continue to expand in dramatic fashion” (Turner).

Using figures from the World Tourism Organization, in 2005 around “617 million people engaged in health

tourism, reflecting an average annual growth of 3.9% between 2000 and 2005 and generating a spending of US$513 billion. Europe is the primary destination for health tourism, with a share of 53.1% of the market in 2005 from 57.5% in 1995. Asia–Pacific is the second most popular destination, with a share of 19.5% edging the Americas (with a share of 16.4%), which previously held second position. The Middle East and Africa are a far fourth and fifth, with comparable shares of 4.7 and 4.8%, respectively. In terms of receipts, again Europe accounts for the biggest share of revenues from health tourism at US$272.6 billion or 53.1% of total international receipts. Asia–Pacific and the Americas have comparable shares at 19.8 and 20.3% of total receipts, respectively, noting however, that the Americas’ share has taken a big dip between 2000 and 2005. In the meantime, Africa and the Middle East combined account for just over 6% of total spending” (Carrera and Bridges).

Procedures and Costs Currently, medical tourism is a niche market, offering non-emergency medical procedures for comparatively low-cost to the United States. These procedures range from “elective cosmetic surgeries to complex, non-emergency joint replacements and heart surgeries, as well as fertility care such as

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in-vitro fertilization. Also, many overseas hospitals are expanding the number of procedures they offer to medical tourists. The Apollo Group Hospitals in India, for example, now offer LASIK corrective eye surgery and dental procedures including root canals, as well as sexual health procedures like vasectomies.

The procedures a hospital is able to offer vary from region to region, as do costs. However, many analysts predict the number of procedures offered will coincide with the United States market. That is to say that as long as health costs continue to rise in the United States, overseas hospitals will continue to add new services to cover the demand for lower cost alternatives” (Burkett).

As noted in the previous table, it is the enormous disparity in costs between the United States and foreign health care markets that drives the medical tourism industry in general and compels American consumers to accept or ignore many of the issues and dangers related to medical tourism. For example, “the average procedure in India is roughly one-tenth of the cost of the same procedure in the United States. In Thailand, the cost of surgery is about one-eighth of that in the United States. Even a more expensive destination like Singapore can provide massive savings. For example, a liver transplant, which would cost some $300,000 in the United States, would cost only $150,000 in Singapore. Such a difference in price, even when travel costs are figured in, creates enormous pressure on the United States health care market. That pressure, thus far, has manifested itself only in increased medical tourism, not noticeably lowered domestic rates” (Burkett).

Business Models The business model of most foreign hospitals is to emphasize quality service, low cost, and an exciting vacation. Such hospitals achieve some of those goals through “service on the broker end, by using American-trained physicians and making access to the ‘vacation time’ of a medical tourism trip easier for the patient. For example, many of the surgeons in India’s large Apollo Hospitals Group trained at the

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most prestigious surgery centers in the United States, including the Galvin Heart Center in Illinois and the Memorial Sloan-Kettering Cancer Institute in New York, among others” (Burkett).

However, some hospitals also focus on their uniqueness from the patient’s home country hospitals. For example, in Slovenia, “medical tourism clinics offer fertility procedures that are not available in other European countries like Italy. These Slovenian hospitals position themselves as health care facilities that are different from the patient’s home country hospitals in what services they offer and, at the same time, appeal to the patient who resists the prevailing ideology in her home country. This type of medical tourism acts as a moral safety valve permitting national parliaments to express local sentiments while simultaneously acknowledging the moral autonomy of those who do not agree with those sentiments” (Burkett) An emerging trend in medical tourism destinations is partnerships emerging between U.S. providers and foreign providers. In order to capitalize on foreign profits, “the U.S. hospitals, and even community hospitals with excess capacity, are forming partnerships with foreign institutions in assuring cost-effective, highest-quality care, and providing follow-up treatment back in the U.S.” (Merrell).

More hospitals than ever are rushing to meet the exacting standards of the Joint Commission International, which has approved 469 distinct accredited or certified organizations in 50 countries to date. The JCI-accredited hospital at which Fred Schuler was treated - Fortis Hospitals in Bangalore, India, is associated with Harvard Medical International - exceeded his expectations: “They picked me up at the airport at 4 a.m. their time and took me to the hospital for X-rays. My room was incredible, the care was phenomenal. I was there in the hospital for seven days and I was in what I consider to be a four- to fivestar health facility” (York).

“The rising costs of medical treatment here have fueled a medical tourism exodus,” says David Boucher, an assistant vice president for Companion Global 05.13

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Impact on U.S. Healthcare System

A telling study of US bankruptcies, conducted by the Harvard Medical School and the Harvard Law School, found that “one half of this nation’s 1,458,000 bankruptcies in 2001 were caused by medical bills.

More than three-quarters were insured at the start of the bankrupting illness. However, 38 percent had lost coverage at least temporarily by the time they filed for bankruptcy” (York).

According to the Centers for Medicare & Medicaid Services (CMS), “more than 70 percent of hospital costs within the United States are labor related; Sherman found that 80 percent of a hospital’s costs are driven by physician decisions. The steadily rising health care costs within the U.S. will continue to fuel the demand for medical tourism. Legislators must consider the implications of rising healthcare costs.

American patients continue to seek medical treatment in foreign hospitals” (Mattoo and Rathindran).

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AVERAGE LIFE EXPECTANCY

The growing trend of medical tourism raises many issues for our US health care system. Government legislators question whether the lower costs offered internationally will affect health care costs in the United States. Medical tourism discussions also raise questions about the quality of care and the reasons for lower costs internationally, compared to the United States. The United States accounts for over “$1.7 trillion of the $3.3 trillion spent annually for worldwide health care—yet the United States ranks 37th in certain quality-of-care measures. Our per capita health care costs are higher than any other country, and twice that of Japan. But our infant mortality rates in blighted inner cities are worse than in third world

countries. At half the per capita cost, Japan has lower infant mortality and longer life spans than the United States. These vexing issues will continue to fuel debate within the US health care system, particularly with regard to the social issues that lead to urban blight and the resulting disparity between urban and suburban health care, as well as the large numbers of uninsured patients in the United States” (Forgione and Smith).

PER CAPITA SPENDING (U.S.$)

Healthcare Services Inc., a subsidiary of Blue Cross and Blue Shield of South Carolina. “This is an explosive trend,” Boucher says; “we are providing a true value-add for our clients.” The subsidiary, Companion Global Healthcare, “interviews the patients; helps them choose the appropriate physician and hospital; obtains their medical records; arranges a phone consultation with the physician; makes all hospital, hotel, and travel arrangements; and often has a concierge person at the remote site host country to handle any problems that might arise” (York).

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Opening health care to capitalism might be expected to drive costs downward through competition in the United States; however, “because hospitals are predominantly fixed-cost institutions, the reduced demand in the United States will actually drive costs per patient case up in the short run, rather than down” (Forgione and Smith).

Furthermore, “it is probable that the extremely lowcost international alternatives to surgeries performed in the United States will persuade insurance companies to begin offering medical tourism as an option to their policyholders. This is especially so as traveling abroad for health care becomes less taboo and major hospitals in foreign countries gain accreditation through the Joint Commission International” (Burkett).

There remain valid concerns about insurance companies offering to cover medical tourism that may outweigh the cost savings and general assurances of quality. First, “outsourcing may have a negative effect on the cost and quality of care in the United States.

Currently, the American system of funding health care, whether through private or employer-spon-

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sored health indemnity insurance or managed care health benefit plans, operates on a cost-spreading model. This system relies on a large pool of persons paying into the plan to cover the cost of health care for any one person who may need care at any given time. If health benefit plans increasingly come to rely on the medical tourism option for a patient’s surgeries, then necessarily the pool of people over which to spread the cost of those same surgeries in the United States is reduced. This may result in a rise in the cost of those surgeries the United States” (Burkett).

Finally, medical tourism will compete for more insurance plan dollars; “while increased competition is traditionally an economic hedge against a static, ultimately inefficient marketplace, such increased competition in the United States health care market may have detrimental effects. The need to lower prices may persuade some health care providers to lower quality to compete. Likewise, a general shift in focus in health care from public trust or right to a straight commercial model may limit the number of persons entering the profession, or in some other attenuated way adversely affect patient care” (Burkett).

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Public Health

Public Health

08 Rugmark School For Girls // India Roberto Romano

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Public Health Introduction Development of medical tourism has followed a growing emphasis on technology and private enterprise, and the attitude that health care can be bought ‘off the shelf ’. Medical technology is constantly evolving, “raising new ethical issues as the body has increasingly become a playground for experimentation and insight. This has posed complex bioethical questions, especially for new and experimental procedures where a variety of differentiated and geographically distinct practices are subordinated to the ‘logic of the market’ in contexts where regulation is weak but where a political economy of hope prevails” (Connell).

Traditionally, upper class individuals travel from developing countries to proven, high-quality healthcare institutions such as the Cleveland Clinic and Harvard Medical Center in pursuit of medical care.

The emerging middle classes across the globe have followed the “earlier diasporic travels of the relatively poor and the Western predilections of rich elites.

Medical tourism has largely reversed an earlier pattern of wealthy patients from around the world travelling to rich world centers, such as London, and resulted in patients – niche tourists – travelling away from affluent global cities to India, Thailand, Mexico and elsewhere. In a very short time medical tourism has changed direction, incorporated bidirectional flows and become increasingly complex. Globalization has intensified, expanded and diversified such movements in the ever-shifting interplay of centre and periphery, as the ‘new’ medical care has shifted from core towards periphery” (Connell).

Social Cost in Destination Countries Perhaps the greatest risk for inhabitants of destination countries is that increased volume of international patients will have adverse effects upon local patients, healthcare facilities and economies. Many countries are investing to become regional biomedical hubs; however, “there will presumably be winners and losers in the struggle for market share of inter-

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“

The first task of the doctor is...political: the struggle against disease must begin with a war against bad government.

- Michel Foucault

national patients. Public resources might better be put into publicly funded health care rather than into promoting for-profit initiatives intended to generate trickle-down effects through the larger economy. In some countries, cost–benefit estimates leading to the conclusion that there will be a significant return on investment of public and private funds are likely to be wrong. India, Thailand and Singapore are already well positioned to attract patients from other countries. It is unclear that Indonesia, Hong Kong, Malaysia, the Philippines, South Korea and Taiwan will all benefit from similar national economic strategies.

Investing public funds into preventive medicine, public health care and basic social infrastructure might generate more predictable population-level benefits” (Turner).

For example, “directing public funds toward specialized medical centers and advanced biotechnologies is a particularly questionable decision when most citizens of a country lack access to basic health care and social services. The phenomenon of ‘crowding out’ is another problem associated with drawing international patients to health care facilities in India, Thailand and Singapore. If large numbers of international patients flow into a country, the cost of health care will likely climb for local patients. Salaries of physicians, nurses and other health care providers will escalate. Health care could become less ac05.13

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cessible to local patients. This problem could disappear if economic benefits ripple through society and entire populations benefit from national economic development. However, if benefits are captured by socioeconomic elites and never reach the poorest members of society, some local citizens could have even worse access to health care than they had prior to the arrival of large numbers of international medical travelers. The challenge international medical travel poses to health equity is perhaps the greatest problem facing countries promoting medical tourism. Singapore promotes international medical travel while also dedicating substantial public resources to preventive medicine and publicly funded health care.

Even with this investment, visitors to Singapore commonly have access to therapies most local citizens cannot afford to purchase” (Turner).

According to international comparative studies, the health equity problem facing Singapore is even more significant in such countries as India, Indonesia, Malaysia and Thailand. With “appropriate financing, auditing and regulatory mechanisms, perhaps revenues generated from international patients could be used to improve access to care for local citizens. However,

if profits from providing care to international patients are not used to cross-subsidize and improve care of local patients, the already massive health equity gap in India and Thailand will widen. What could emerge in many countries is what has already taken shape in India. Elite, high-quality medical facilities could offer health care that is unaffordable to all but a tiny segment of local individuals. Access to the best medical facilities would be limited to the wealthiest local citizens and paying patients from other countries.

Instead of contributing to broad social and economic development, the provision of care to patients from other countries might exacerbate existing inequalities and further polarize the richest and poorest members of society” (Turner).

The poor in India have no access to healthcare for two reasons: it is either too expensive or not available. Natives comment “we have doctors but they are busy treating the rich in India. Now we have another trend. For years we have been providing doctors to the western world. Now they are coming back and serving foreign patients at home” (Connell).

Medical tourism serves those with the ability to pay,

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where service is purely a function of the ability to pay, redeeming features are elusive in a system that tolerates striking inequalities in income and health.

In this perspective, medical tourism is both symbol and manifestation of the failures of privatization and national healthcare systems. Most criticisms of medical tourism are actually criticisms of capitalism and privatization, albeit both epitomized in medical tourism, and implicitly of the failings of health systems, especially in developing countries, to provide more effective and equitable health care” (Connell).

10 even when patients are under-insured: “at source medical tourism is inequitable. After all, it emerged from the inability (but also unwillingness) of some patients to pay for medical treatment in their home countries for whatever reason. As in the UK: ‘Fertility tourism has always happened and will continue to happen. The real tragedy is that those with money can always go overseas, but the people who haven’t two brass farthings to rub together are always the people who lose out.’ While fertility tourism is particularly expensive and exclusive, in Yemen and elsewhere the relatively poor are unable to take advantage of any form of medical tourism, but have no effective local health services’ (Connell).

Medical tourism reinforces privatization alongside a technological view of the health system where “medical services can be bought ‘off the shelf ’ from the lowest cost provider, rather than well-being created by remedying the social, political and economic determinants of health: an analogy with the relationship between cosmetic surgery and diet and exercise.

Medical tourism consequently represents the full integration of medicine with global capitalism and, 17

On top of this, infrastructural growth will contribute several detrimental factors to the developing countries’ public health. “The natural greenery or forest cover of a region is compromised in order to accommodate more buildings, hospital facilities, roads, treatment or diagnostic centers etc. To supplement the above, there is a continuous discharge of polluted air, solid-toxic medical waste, litters of sewage consisting of oil and chemicals. Architectural, noise and visual pollution also has a direct negative impact on the atmosphere” (Hall).

Quality of Care Comparatively inexpensive care in developing countries can be high-quality health care. However, it is possible that “travelers assume significant additional risk when they obtain out-of-country medical procedures. Quality of care is a legitimate concern when low prices and sales packages are used to attract patients to particular health care facilities. To ensure that the provision of health care remains profitable, there are many ways in which health care providers can reduce costs and maximize earnings. Some of these techniques—using older medical equipment during operations, providing inferior quality medications, utilizing poorly trained health care providers, maintaining inadequately stocked operating clinics or emergency rooms, implanting older-generation medical devices—pose significant risks to patients” (Turner).

Along these lines, there is no universal international

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Public Health

Medical Malpractice In conjunction with the quality issues in some developing countries, the regulatory and legal uncertainties are also important. The U.S. health care system provides patients with some recourse through medical malpractice laws. Most states require physicians to have liability insurance, and the insurance is regulated by individual states. The purpose of medical malpractice insurance is to “cover doctors and other professionals for liability claims arising from the treatment of patients. The laws are established in order to provide some form of compensatory relief if doctors deviate from accepted practice standards and cause injury to patients” (Forgione and Smith).

11 governmental body for accrediting hospitals, physicians, or other health care professionals. While the Joint Commission International does accredit some hospitals, there is still a “worry that physicians, nurses, and other health care providers in international patient hospitals may not have the same training or expertise as their American counterparts. Admittedly, this concern is being addressed in part by the major medical tourism hospitals themselves, as the subject of accreditation and provider training is a marketing point. As such, there is an internal motivation to bring services up to international standards.

However, neither a physician’s training nor an international hospital’s accreditation are consistent from one destination country to another, so the possibility of a potential medical tourist using higher-risk services is greatly increased. The history of health care in America is, in one sense, a history of this country’s unease with an unchecked, unregulated medical services industry. This policy is reflected in the large number of regulatory bodies and boards that we have over our health care system, and is a major concern with medical tourism” (Burkett).

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Unlike the United States, many of the developing countries offering medical services to US patients have lower costs because they lack well-established malpractice laws. “Proving doctor negligence in India is quite difficult because many hospitals do not have established mechanisms to manage complaints from patients. In Singapore and Malaysia, the courts defer to the doctors to determine whether the standards of care have been breached. For those countries that do offer some form of malpractice relief for patients, damages are often limited” (Forgione and Smith).

Medical malpractice in conjunction with medical tourism works on two fronts: affecting a patient in the foreign country as well as domestically. “If a patient is injured by a doctor or hospital overseas, US providers and insurers may be reluctant to bear the risk and cost burden of trying to correct the medical problem. Injured patients may then take recourse by going to emergency rooms of hospitals, where the cost to treat patients is the highest of most venues.

These legal uncertainties and malpractice complications often provoke US insurance plans to be cautious in covering procedures in developing countries” (Forgione and Smith).

A major legal and privacy issue within the US healthcare system is the Health Insurance Portability and

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Public Health

Outflow of Human Resources Both increasing demand and more financial incentives in the private sector have resulted in the outflow of human resources, particularly physicians, from rural public facilities to urban private hospitals.

“The income gap between private and public health personnel is highest among doctors, a difference of up to 6–11-fold in 1997, hence the highest outflow” (Cha-Aim and Suwit).

12 Accountability Act of 1996 (HIPAA). This federal law was established to “protect patient information and limit how patient health information can be used or shared. Stringent regulations must be followed, or civil penalties may be assessed at $100 per failure to comply (with a maximum of $25,000 per year). Criminal penalties may also be assessed against someone who knowingly obtains or discloses individually identifiable health information that is in violation of HIPAA. The stringent HIPAA laws apply in the United States, and US-based health plans must follow these rules, even for service providers in another country; however, neither HIPAA nor any near-equivalent informational security provision applies in most foreign countries. There are exceptions in Europe, where privacy protection is generally thorough. But Asia is not considered to be very strict in the area of patient privacy. These policy and infrastructure issues may not always be considered by patients thinking about the potential risks of obtaining health care in foreign countries” (Forgione and Smith).

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“Because technology is more mobile than labor resources, a country such as Thailand can import the former, upgrade the latter, and bolster its comparative advantage vis-à-vis the developed world. But to do so successfully, it has to invest a disproportionate share of finite resources in services for the affluent, thus distorting any redistributive effect of better care.

And the presence of well-endowed hospitals tends to prompt an internal brain drain from the public to the private sector, thereby decreasing equity in access to health care for the local population. This siphoning off of health personnel from the public to the private sector is already occurring in Thailand” (Cha-Aim and Suwit).

A Thai doctor observed “Each time a foreigner sees a Thai doctor at ‘foreigner prices’ he takes away an opportunity for a Thai person to see the same doctor at normal Thai fees. In other words, this program, while presumably bringing foreign capital to our hospitals, is sucking medical care from our own people” (Connell). The effect of these trends reinforces a two-tiered health system, with different standards for different economic classes.

Continuum of Care When medical treatment is sought from abroad, the normal continuum of care is interrupted. Not surprisingly, “evidence of outcomes for medical tourist treatments is limited and reports are difficult to obtain and verify. Little is known about the relative clinical outcomes for particular treatments, institutions, clinicians and localities. There is scant evidence on

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Public Health

13 long or short-term follow-up of patients dispersing to home countries following treatments at the range of destinations. Patient follow-up is rare; a study of 20 patients presenting at a German university hospital after overseas refractive surgery, concluded there was insufficient management of complications and a lack of post-operative care. For ‘transplant tourism’, Canales’ study of kidney patients transplanted abroad found there was a high incidence of serious post-operative infections (6 serious infections for 4 patients), although graft survival and function were concluded to be good” (Lunt and Carrera).

Therefore, medical tourism increases the risk of nosocomial infections or ‘healthcare acquired infections.’ At any time, “over 1.4 million people worldwide suffer from infectious complications acquired in hospital with the elderly being particularly vulnerable” (Hall).

Biosecurity Risks Health risk is inherent to human mobility. However, medical tourism is intrinsically different with respect to increasing biosecurity risk because “individuals who engage in medical tourism are deliberately travelling to a medical environment and engaging in medical practices that expose them to pathogens an microbiologic fauna and flora that are qualitatively different from those found in their home environment. Indeed, one of the lessons of SARS and recent pandemics is that healthcare institutions have emerged as a major potential source of infection” (Hall).

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Conclusion

Conclusion

14 Samsung International Hospital // Seoul, South Korea NBBJ

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Conclusion

Conclusion Widespread marketing of ‘medical tourism’ fails to acknowledge the harms that could flow from globalized health care. For-profit hospitals in India, Thailand and other countries could “undermine quality of care at public health care facilities in these regions.

With higher salaries at private facilities, public health care institutions might suffer a ‘brain drain’ as doctors, nurses and other health care providers move to better-paid jobs. Fewer health care providers at public institutions will undermine health equity and even further reduce access to care in communities where access to basic health services is already severely circumscribed” (Turner).

The medical tourism industry also contributes to the further commodification of health services. “Countries offering universal health care emphasize treating patients according to need. The medical tourism industry arranges care based upon what customers can afford. Sufficiently wealthy clients can arrange travel packages with numerous amenities. Comparatively poor customers must settle for the cheapest services they can find. Some patients will presumably receive excellent care. In other instances, the desire of destination hospitals to maximize profits and minimize expenses could have a significant effect upon quality of care and patient safety” (Turner).

Medical tourism is the “outcome of uneven social and economic development, alongside the convergence of biotechnological development in medicine, middle-class modernity and mobility and the evolution of the airline industry. That is evident with cosmetic surgery accompanying the global celebrity and media age and new vulnerabilities in the global economy. Medical tourism has been a triumph for the private sector, involving a series of players at various levels including the state, public and private health-care providers, regulatory bodies, MTCs and individual patients/tourists but where the market has held the upper hand” (Connell).

In the absence of local support, and where patients often find it difficult enough to evaluate and select even a local neighborhood healthcare provider, the growth of medical tourism has exploded. It has 22

15 “offered greater choice to patients (increasingly referred to as ‘health consumers’) in all countries, but alongside a cult of individualism, and where the poor cannot make extensive or expensive ‘choices’. The private sector has distorted some healthcare systems by shifting resources from the poor. The best metropolitan hospitals, where medical tourism is a part of their activities, have drawn skilled resources from regional areas and smaller hospitals as part of a continued process combining privatization, urban bias and the weakening and withdrawal of national planning ”(Connell). As inherent inequality has excluded the poor and geographically distant, medical tourism is playing an increasing role in widening global healthcare divides.

Proposed Solutions Any effort limiting the growth of medical tourism would be futile; through globalization, the world is ‘flat’ with more people having ability and means to travel. What is necessary are regulations addressing the social, economic, and health issues posed by

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Conclusion

medical tourism. These regulations should work on two fronts: (A) increased emphasis on the accreditation of international hospitals; (B) and engaging GATS in steering medical tourism toward public health initiatives. Such regulations would work to achieve the legitimate governmental goal of ensuring that the medical tourism is of high quality and delivered in order to prevent disease, prolong life and promote health on global level.

First, before any regulation of medical tourism can have any real effect, more must be learned about the destination hospitals of the medical tourism network. International accreditation procedures must be adopted that include, but are not limited by, those imposed by the Joint Commission International.

Currently, the Joint Commission International has established equitable guidelines in meeting these ends, yet there is still concern that physicians, nurses, and other health care providers in international patient hospitals may not have the same training or expertise as their American counterparts. Such accreditation will allow Congress to propose rational legislation regulating medical tourism accreditation and the truthful comparison of destination hospitals.

Furthermore, “a common regulatory platform and reporting system should serve as the basis of an assessment of quality of care to allow for comparison of indicators as facilitated by international accreditation and certification. Information asymmetries are particularly pronounced in light of the element of distance’ including jurisdiction. There is a lack of comparative quality and safety data, and knowledge of infection rates for overseas institutions and reporting of adverse events. The literature has reported instances of infection outbreak for US patients aris-

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ing from treatment at an overseas ‘medical tourist’ facility. Whilst there is evidence regarding the occurrence of adverse events in UK hospitals there is no comparative overseas data and few safeguards” (Lunt and Carrera).

Secondly, engaging the General Agreement on Trade in Health Services toward public health issues automatically leads to showing the value gained beyond individual heath care. When considering these treaties, it is important that their objectives are transparent, consistent, and predictable in international economic policies. They do this through creating a credible, reliable, and legally binding system of international trade rules, ensuring an equitable treatment of exporters, stimulating economic activity, and promoting economic development. The philosophical basis is that “liberalization will encourage a global increase in efficiency, through the traditional economic arguments relating to comparative advantage, ensuring consumers continued product availability and reducing the economic power of individual economic operators. In this sense, they have a lot to offer public health through securing stability and predictability in trading health related goods, services, and people.” (Richard Smtih) In summary, in order to address the challenges and issues posed by medical tourism, we must not view national health, or evaluate interventions and policies to improve health, in isolation from the rest of the world. If we want to make sure we minimize the risks that medical tourism poses, and capitalize on the opportunities it offers, then it is vital that national governments, accreditation bodies, health insurance companies, and public health professionals begin to engage with these proposed solutions.

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References

References

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20 Turner, Leigh. “‘First world health care at third world prices’: globalization, bioethics and medical tourism.” BioSocieties 2.3 (2007): 303-325.

21 York, Diane. “Medical tourism” Journal of Continuing Education in the Health Professions 28.2 (2008): 99-102.

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17 Samsung International Hospital // Seoul, South Korea NBBJ

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