Medical tourism

Medical tourism (also called medical travel,health tourism or global healthcare) is a term initially coined by travel agencies and the mass media to describe the rapidly-growing practice of traveling to another country to obtain health care.
Such services typically include elective procedures as well as complex specialized surgeries such as joint replacement (knee/hip), cardiac surgery, dental surgery, and cosmetic surgeries. The provider and customer use informal channels of communication-connection-contract, with less regulatory or legal oversight to assure quality and less formal recourse to reimbursement or redress, if needed.
Leisure aspects typically associated with travel and tourism may be included on such medical travel trips. Prospective medical tourism patients need to keep in mind the extra cost of travel and accommodations when deciding on treatment locations.
A specialized subset of medical tourism is reproductive tourism, which is the practice of traveling abroad to undergo in-vitro fertilization and other assisted reproductive technology treatments.

History
The concept of medical tourism is not a new one. The first recorded instance of medical tourism dates back thousands of years to when Greek pilgrims traveled from all over the Mediterranean to the small territory in the Saronic Gulf called Epidauria. This territory was the sanctuary of the healing god Asklepios. Epidauria became the original travel destination for medical tourism.
Spa towns and sanitariums may be considered an early form of medical tourism. In eighteenth century England, for example, medtrotters visited spas because they were places with supposedly health-giving mineral waters, treating diseases from gout to liver disorders and bronchitis.

Description
Factors that have led to the increasing popularity of medical travel include the high cost of health care, long wait times for certain procedures, the ease and affordability of international travel, and improvements in both technology and standards of care in many countries.
Medical tourists can come from anywhere in the world, including Europe, the UK, Middle East, Japan, the United States, and Canada. This is because of their large populations, comparatively high wealth, the high expense of health care or lack of health care options locally, and increasingly high expectations of their populations with respect to health care.
A large draw to medical travel is convenience and speed. Countries that operate public health-care systems are often so taxed that it can take considerable time to get non-urgent medical care. The time spent waiting for a procedure such as a hip replacement can be a year or more in Britain and Canada; however, in Singapore, Hong Kong, Thailand, Cuba, Colombia, Philippines or India, a patient could feasibly have an operation the day after their arrival. In Canada, the number of procedures in 2005 for which people were waiting was 782,936. Additionally, patients are finding that insurance either does not cover orthopedic surgery (such as knee/hip replacement) or imposes unreasonable restrictions on the choice of the facility, surgeon, or prosthetics to be used. Medical tourism for knee/hip replacements has emerged as one of the more widely accepted procedures because of the lower cost and minimal difficulties associated with the traveling to/from the surgery. Colombia provides a knee replacement for about $5,000 USD, including all associated fees, such as FDA- approved prosthetics and hospital stay-over expenses. However, many clinics quote prices that are not all inclusive and include only the surgeon fees associated with the procedure. According to an article by the University of Delaware publication, UDaily:
“
The cost of surgery in India, Thailand or South Africa can be one-tenth of what it is in the United States or Western Europe, and sometimes even less. A heart-valve replacement that would cost $200,000 or more in the U.S., for example, goes for $10,000 in India--and that includes round-trip airfare and a brief vacation package. Similarly, a metal-free dental bridge worth $5,500 in the U.S. costs $500 in India, a knee replacement in Thailand with six days of physical therapy costs about one-fifth of what it would in the States, and Lasik eye surgery worth $3,700 in the U.S. is available in many other countries for only $730. Cosmetic surgery savings are even greater: A full facelift that would cost $20,000 in the U.S. runs about $1,250 in South Africa." ”
Popular medical travel worldwide destinations include: India, Brunei, Cuba, Colombia, Hong Kong, Hungary, Jordan, Lithuania, Malaysia, The Philippines, Singapore, South Africa, Thailand, and recently, Saudi Arabia, UAE, Tunisia and New Zealand.
Popular cosmetic surgery travel destinations include: Argentina, Bolivia, Brazil, Colombia, Costa Rica, Cuba, Mexico and Turkey. In South America, countries such as Argentina, Bolivia, Brazil and Colombia lead on plastic surgery medical skills relying on their experienced plastic surgeons. It is estimated that 1 in 30 Argentineans have had plastic surgery procedures, making this population the most operated in the world after the US and Mexico.[citation needed] In Bolivia and Colombia, plastic surgery has also become quite common. According to the "Sociedad Boliviana de Cirugia Plastica y Reconstructiva", more than 70% of middle and upper class women in the country have had some form of plastic surgery. Colombia also provides advanced care in cardiovascular and transplant surgery.
In Europe Belgium, Poland and Slovakia are also breaking into the business. South Africa is taking the term "medical tourism" very literally by promoting their "medical safaris". However, perceptions of medical tourism are not always positive. In places like the US, which has high standards of quality, medical tourism is viewed as risky. In some parts of the world, wider political issues can influence where medical tourists will choose to seek out health care.
Health tourism providers have developed as intermediaries to unite potential medical tourists with provider hospitals and other organisations. Companies are beginning to offer global health care options that will enable North American and European patients to access world health care at a fraction of the cost of domestic care. Companies that focus on medical value travel typically provide nurse case managers to assist patients with pre- and post-travel medical issues. They also help provide resources for follow-up care upon the patient's return.

International healthcare accreditation
Because standards are important when it comes to health care, there are parallel issues around medical tourism, international healthcare accreditation, evidence-based medicine and quality assurance.
In the United States, Joint Commission International (JCI) fulfills an accreditation role, while in the UK and Hong Kong, the Trent International Accreditation Scheme is a key player. The different international healthcare accreditation schemes vary in quality, size, cost, intent and the skill of their marketing. They also vary in terms of cost to hospitals and healthcare institutions using them. Increasingly, some hospitals are looking towards dual international accreditation, perhaps having both JCI to cover potential US clientele and Trent for potential British and European clientele.
Other organizations include:
The Society for International Healthcare Accreditation (SOFIHA), a free-to-join group providing a forum for discussion and for the sharing of ideas and good practice by providers of international healthcare accreditation and users of the same. The primary role of this organisation is to promote a safe hospital environment for patients.HealthCare Tourism International, the first US-based non-profit to accredit the non-clinical aspects of health tourism, such as language issues, business practices, and false or misleading advertising prevention. The group provides accreditation for all major groups involved in the health tourism industry including hotels, recovery facilities, and medical tourism booking agencies.

Risks and rewards
Medical tourism carries some risks that local medical procedures do not. Should complications arise, patients might not be covered by insurance or able to seek compensation via malpractice lawsuits. However new insurance products are available that do protect the patient should a medical malpractice occur overseas. Some countries currently sought after as medical tourism destinations provide some form of legal remedies for medical malpractice. However, this legal avenue is unappealing to the medical tourist. Advocates of medical tourism advise prospective tourists to evaluate the unlikely legal challenges against the benefits of such a trip before undergoing any surgery abroad. Patients should also be aware that the quality of post-operative care can also vary dramatically, depending on the hospital and country, and may be different from US or Western standards.
Some countries, such as India, Malaysia, Costa Rica, or Thailand have different infectious diseases than Europe and North America, and different prevalences of the same diseases compared to nations such as the U.S., Canada, and the UK. Exposure to disease without having built up natural immunity can be a hazard for weakened individuals, specifically for gastrointestinal diseases (e.g Hepatitis A, amoebic dysentery, paratyphoid) which could weaken progress, mosquito-transmitted diseases, influenza, and tuberculosis (e.g., 75% of South Africans have latent TB). International hospital accreditation with Trent or JCI, mentioned earlier, may be of value here when people are trying to choose a destination for their procedure.
Also, travel soon after surgery can increase the risk of complications, as can vacation activities. For example, scars will be darker and more noticeable if they sunburn while healing.[7] Long flights can be bad for those with heart (thrombosis) or breathing-related problems. To avoid these problems medical tourism patients often combine their medical trips with vacation time set aside for rest and recovery in the destination country.
However, because in poor tropical nations diseases run the gamut, doctors seem to be more open to the possibility of any infectious disease, including HIV, TB, and typhoid, there are cases in the West where patients were consistently misdiagnosed for years because such diseases are perceived to be "rare" in the West. For hospitals and doctors seeking to provide medical tourism services, there is the risk of being sued by a disgruntled patient, so medical indemnity services such as those provided by the Medical Protection Society are essential.
Destinations

North America

Canada
Canada has entered the medical tourism field. In comparison to U.S. health costs, medical tourism patients can save 30 to 60 percent on health costs in Canada. Canada's quality of healthcare is cited by the World Health Organization as equal to if not better than that of the U.S. in most categories.

Cuba
Cuba has been a popular medical tourism destination for more than 40 years. Thousands of patients travel to Cuba, particularly from Latin America and Europe, attracted by the "fine reputation of Cuban doctors, the low prices and nearby beaches on which to recuperate."[11] In 2006, Cuba attracted nearly 20,000 health tourists. Medical treatments included joint replacement, cancer treatment, eye surgery, cosmetic surgery and addictions rehabilitation. Costs are about 60 to 80 percent less than US costs. For example, Choice Medical Services, a health tourism provider, provides a hip replacement in Cuba for US$5,845/C$6120/€4227. Cuba has hospitals for Cuban residents and others that focus on serving foreigners and diplomats. In the 2007 American documentary film, "Sicko," which criticizes the US healthcare system, producer Michael Moore leads a group of uninsured American patients to Cuba to obtain more affordable medical treatment. "Sicko" has greatly increased foreigners' interest in Cuban healthcare. A recent Miami Herald story focused on the high quality of health care that Canadian and American medical tourism patients receive in Cuba. The Cuban government has developed Cuban medical tourism to generate income for the country. Residents of Canada, the UK and most other countries can travel to Cuba without any difficulty; a tourist visa is generally required. For Americans, however, because of the US trade policy towards Cuba, travelers must either obtain US government approval, or, more frequently, travel to Cuba from Canada, Mexico, the Bahamas, Jamaica or the Dominican Republic. Cuban immigration authorities do not stamp the passports of US visitors so that Americans can keep their travels a private matter.
However, few Cuban hospitals as yet have international healthcare accreditation.

Dominican Republic

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One of the medical tourism destinations nearest to the US mainland is the Dominican Republic. The country has become a popular destination for plastic surgeries, hip-replacements, knee replacements, bariatric surgeries, eye surgeries and all other types of surgeries and medical treatments. The costs are generally 50 to 75 percent less than cost of similar procedures in the US.

Mexico
Americans, particularly those living near the Mexican border, now routinely cross to Mexico for medical care. Popular specialties include dentristry and plastic surgery. Mexican dentists often charge one-fifth to one-fourth of US prices, while other procedures typically cost a third what they would in the US. This trend has alarmed American healthcare providers who, fearing a loss of business, warn patients away from Mexico. "The phenomenon has unsettled US-based dentists who tell horror stories of rampant infections, undetected cases of oral cancer and shoddy work south of the border -- claims hotly disputed by Mexican dentists." "In Texas, legislators explored the possibility of allowing health maintenance organizations to operate on both sides of the border. However, physicians in south Texas lobbied against the changes, arguing that local doctors could not compete with the lower costs in Mexico". US doctors point out that the Mexican legal system makes it almost impossible to sue Mexican doctors for malpractice. However, many who travel to Mexico for care report that they are satisfied. According to a report commissioned by Families U.S.A., a Washington advocacy group for health-care issues, "About 90 percent [feel] the care they had received in Mexico had been good or excellent. About 80 percent rated the care they had received in the United States as good or excellent". Indeed "some U.S. dentists ... have conceded to the competition and begun a 'reverse migration' opening offices in Mexico to take advantage of lower costs". American insurers are providing coverage for travelers, as the out-of-pocket costs to them are much lower. "With healthcare costs in the United States continuing to rise, many employers in Southern California are turning to insurance plans that send their workers to Mexico for routine care, plans that are growing by nearly 3,000 people a year".
In addition to dental and plastic surgery, Mexican hospitals are popular for bariatric surgery for weight loss, considered an elective procedure that is not covered by some US insurers. A popular bariatric procedure, lap band surgery, which was approved by the FDA in the US in 2001, has been performed for longer by Mexican surgeons.
Panama

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In Panama, health and medical tourism is growing rapidly. Factors drawing medical tourists include Panama's tourist appeal, position as a hub for international travel, and use of the dollar as the official currency. More important, Panama's medical professionals are trained around the world, use the latest technologies and medications, and have earned a high reputation. Many of Panama’s doctors are bilingual, board certified, and accustomed to working with the same medical equipment and technology used in the United States and Europe. On most procedures, Panama offers savings of more than 50% compared to the US and Europe. For example, Dental implants cost an average of $2,500 per implant in the US or Canada. In Panama, the same procedure with board and lodging, personal tour guide, and transportation is available at a much lower cost.
Popular procedures include dental implants, plastic surgery, assisted reproduction, cardiology, cosmetic dentistry, pulmonology and orthopedics. Panama's hospitals have affiliations to international organizations such as: Baptist Health International of Miami, Cleveland Clinic, Tulane Health Science Center, Johns Hopkins International, Miami Children's Hospital, University of Nebraska Medical Center, The Kendall Medical Center in Florida, and Harvard Medical Faculty and Physicians at Beth Israel Deaconess Medical Center in US.

South America

Colombia
Colombia has been treating foreign patients for years, especially for cosmetic and eye surgery. Colombia has also provides advanced cardiovascular and transplant surgery. What often compels persons to seek transplant surgery offshore is not only cost considerations, but waiting lists (such as in the US) or the lack of an organized organ inventory and donor system in the home country. Colombia has such an organ donor and banking system which makes organs available to foreigners with certain legal restrictions. Orthopedic surgeries, such as knee and hip replacements, are done in Colombia with US-made, (FDA-approved) prosthetics at a fraction of the cost.
Colombia has many surgeons that have either trained and/or practiced in other countries such as the US and Europe. Salaries for doctors, nurses, and supporting personnel in Colombia are about 20% of US salaries for similar occupations even though they are required to have the same level of education and job skills. Real estate costs related to medical care facilities are also a fraction of what they are in the US
One advantage of Colombia for those from the US and Canada is ease of travel and close proximity. Colombia offers cheaper airfares from the US and Canada (and some European countries) than other more-distant destinations, and does not have the visa restrictions of other countries currently in the medical tourism market.

Asia/Pacific

Hong Kong
Hong Kong has 12 private hospitals and more than 50 public hospitals. A wide range of health care services are offered. All 12 of Hong Kong's private hospitals have been surveyed and accredited by the UK's Trent Accreditation Scheme since early 2001. This has been a major factor in the ascent of standards in Hong Kong's private hospitals. The Trent scheme works closely with the hospitals it assesses to generate standards appropriate to the locality (with respect to culture, geography, public health, primary care interfaces etc.), and always uses combinations of UK-sourced and Hong Kong-sourced surveyors. Some of Hong Kong's private hospitals have now gone on to obtain dual international accreditation, with both Trent and JCI (and have therefore attained a standard surpassing some of the best hospitals in Thailand and Singapore). Others are looking towards dual international accreditation with Trent and the Australian group. Hong Kong public hospitals have yet to commit to external accreditation.

India
India is known in particular for heart surgery, hip resurfacing and other areas of advanced medicine. The government and private hospital groups are committed to the goal of making India a leader in the industry. The industry's main appeal is low-cost treatment. Most estimates claim treatment costs in India start at around a tenth of the price of comparable treatment in America or Britain. Estimates of the value of medical tourism to India go as high as $2 billion a year by 2012. The Indian government is taking steps to address infrastructure issues that hinder the country's growth in medical tourism.
The south Indian city of Chennai has been declared India's Health Capital, as it nets in 45% of health tourists from abroad and 30-40% of domestic health tourists.Dental care has also caught on in India, with tourists coupling stays in cities like Udaipur with general check-ups and complex procedures.

Malaysia
Malaysia has ambitions to develop itself as a medical tourism hub. The country has excellent hospitals, English is widely spoken, and many staff have been trained to a high level in the UK or in the US. There is a highly active Association for Private Hospitals of Malaysia working to develop medical tourism.[27] While Malaysia has a national accreditation scheme (MSQH), few of Malaysia's hospitals currently hold international healthcare accreditation.

New Zealand
New Zealand is a relatively new player to the medical travel market, focusing on non-acute surgical procedures and fertility treatment. Like other Commonwealth countries, New Zealand's medical system is based on the British health system. Most of its specialist physicians have received training in New Zealand and the US or the UK, and all use English as their first language. The costs of private healthcare are significantly cheaper than the US or the UK, with packages (airfare, accommodation, medical service etc) for procedures like hip replacement, or coronary artery bypass costing in total approximately 40% of the procedure cost alone in the US. Many private hospitals in New Zealand are accredited by the national accreditation agency Quality Health New Zealand (QHNZ). QHNZ, like JCI, is a member of the International Society for Quality in healthcare or ISQua.

Philippines
The Philippines has been growing as a destination for medical tourism. Procedures can be performed at a fraction of the amount that a patient would spend on the same procedure in the US or Europe. Philippine medical and nursing curricula are more challenging than in many in Southeast Asia, and many Filipino doctors have acquired their postgraduate or fellowship training from well-known institutions in the US, the UK and other developed countries.
Medical centers in Metro Manila have complied to ISO standards, and are periodically and regularly undergo accreditations from Philippine's Department of Health. Others have already accredited by the American accreditation group Joint Commission International (JCI), while some are looking at UK-sourced hospital accreditation.]

Singapore
Singapore Medicine is a multi-agency government initiative that aims to develop Singapore into a leading destination for health care services. In 2005, some 374,000 visitors came to Singapore purely to seek healthcare.[29] Many patients come from neighboring countries, such as Indonesia and Malaysia. Patient numbers from Indochina, South Asia, the Middle East and Greater China to Singapore are also growing. Patients from developed countries such as the United States and the UK are beginning to choose Singapore as their medical travel destination for relatively affordable health care services in a clean cosmopolitan city.

Thailand
Medical tourism is a growing segment of Thailand's tourism and health-care sectors. In 2005, one Bangkok hospital took in 150,000 treatment seekers from abroad. In 2006, medical tourism was projected to earn the country 36.4 billion baht. Thailand offers everything from cardiac surgery to organ transplants at a price much lower than the US or Europe, in a safe, clean environment. Thai medicine also features a higher, more personalized level of nursing care than westerners are accustomed to receiving in hospitals at home. One patient who received a coronary artery bypass surgery at Bumrungrad International hospital in Bangkok said the operation cost him US$12,000 (8,200 euros), as opposed to the $100,000 (68,000 euros) he estimated the operation would have cost him at home.[31]
Hospitals in Thailand are a popular destination for other Asians. Another hospital that caters to medical tourists, Bangkok Hospital, has a Japanese wing and Phyathai Hospitals Group has interpreters for over 22 languages, besides the English-speaking medical staff. When Nepal Prime Minister Girija Prasad Koirala needed medical care in 2006, he went to Bangkok.[32]
One Thai hospital, Bumrungrad International, states that many of its doctors and staff are trained in the UK, Europe and the US. Bumrungrad International was accredited most recently in 2005 in order to ensure an international standard of medical services.[33] The modern Thai medical system shares in an Anglo-U.S. inheritance, as Prince Mahidol of Songla, the King's father, earned his MD degree from Harvard Medical School in the early 20th century. Prince Mahidol and another member of the Thai Royal Family paid for an American medical education for a group of Thai men and women.[citation needed] Prince Mahidol also convinced the Rockefeller Foundation to provide scholarships for Thai citizens to study medicine and nursing.[citation needed] Funds from the Rockefeller Foundation were also used to help build modern medical training facilities in Thailand. The men and women who studied medicine and nursing as a result of Prince Mahidol's efforts became the first educators for the modern Thai medical system.[citation needed]
Today many Thai physicians hold US or UK professional certification. Several Thai hospitals have relationships with educational facilities in the US and UK (for example, Sheffield Hallam University has links with Bangkok}. The US Consular information sheet gives the Thai health care system high marks for quality, particularly facilities in Bangkok, although the World Health Organization ranks the Thai healthcare system at number 47, which is below the USA's ranking at 37 and the United Kingdom's ranking at 18. The UK's Foreign and Commonwealth Office web site states "There are excellent international hospitals in Bangkok but they can be expensive".
While a very small percentage of Thai are internationally accredited, there are a growing number of hospitals with Joint Commission accreditation. Again, international hospital accreditation may be one way for hospitals to demonstrate their worth, and increasingly Thai hospitals competing for business in this sector may need to expand their international accreditation, including looking towards other international healthcare accreditation schemes sourced outwith of the US, to augment their appeal if they are to remain competitive.

Europ
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Germany
Germany has long been a medical tourism destination for people from the Middle East and North Africa. Now with a reduction in tension between East and West, many Russians and other Eastern Europeans are seeking treatment in Germany. British and Canadians, no longer willing to wait for treatment in their home country, are also traveling to Germany for treatment. Americans are also heading to Germany for the latest in spine surgery and novel cancer treatments and much lower prices than they would pay in the US. However, few German hospitals as yet have international healthcare accreditation.

Malta
Malta has a strong medical heritage and possesses a high-quality healthcare system modeled on the British system. The population is English-speaking. Malta is part of the European Union and has the euro as its currency. There are a number of private hospitals within Malta (see List of hospitals in Malta) which are developing medical tourism, especially for UK residents. As yet, Maltese hospitals have not engaged in international healthcare accreditation.

Portugal
Portugal's health care system was highly rated by the World Health Organization's year 2000 ranking of the world's health systems, rated 12th of 191 countries. This is a European Union country with regulatory bodies that certify doctors and health facilities, thereby protecting patients’ rights. Proximity to the US and Northern Europe reduce patients’ travel risks, while Portugal's mild climate is well-suited for convalescence. English is widely spoken by the majority of the population and Portugal is well known for its low crime rate. Dental clinics and cosmetic surgery facilities are popular. Prices are low when compared with similar procedures performed in the UK or the US. Other medical procedures include orthopedics, cardiology and eye surgery.

Spain
Spain's strong economy over recent years have provided for modern hospitals and well-trained health care professionals, making it an up-and-coming medical tourism destination.

Turkey
Turkey has attracted hundreds of thousands of tourists form Europe seeking for health care.

Ukraine
Ukraine features modern dental clinics with high-quality equipment, materials and effective anesthetics. They provide patients with dentistry services at lower cost in comparison with Western and Russian clinics. Other popular medical tourism offerings in Ukraine include spas, ophthalmology (eye surgery), plastic]] surgery, and mud baths. As yet, Ukraine medical clinics have yet to seek international healthcare accreditation.

Israel
Israel is emerging as a popular destination for medical tourists. Its modern, field-leading set of physicians and medical facilities are often used by international patients. In 2006, 15,000 foreigners travelled to the country for medical procedures, bringing in $40 million of revenue. Medical tourists choose Israel for several reasons. Some come from European nations such as Bulgaria and Cyprus where certain procedures are not available. Others come to Israel, perhaps most commonly from the US, because they can receive quality health care at a fraction of the cost it would be at home, for both surgeries and in-vitro fertilization treatments. Other medical tourists come to Israel to visit the Dead Sea, a world-famous therapeutic resort.
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