Outsourcing health care: The global growth of medical tourism

Outsourcing health care: The global growth of medical tourismGuest contributor Jill Hodges is a Seattle-based writer and lead editor of a new book Risks and Challenges in Medical Tourism. This is the first of her two-part series examining the growth of this globalized health industry. Here’s the second, a focus on Panama.

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By Jill Hodges

In some respects, the growth of the medical tourism industry relies on the failures of domestic health systems.

“Medical tourists” travel from the US to Central and South America for affordable treatments, from the UK to India for shorter waits, from Nigeria to Europe for decent quality services.

As frustration with the US health care system mounts, so do calls to outsource our health care.

The hope is that medical tourism can provide fixes not only for individual patients, but also for our health system—that US patients seeking less expensive bariatric surgery in Colombia or cancer treatments in Singapore could reduce our overall health care tab. and that global competition potentially could encourage greater efficiency in the US.

Medical tourism is, in one sense, a neglected facet of global health one which could perhaps help achieve the goal of expanded access to care or, conversely, undermine basic public health in low – and middle-income countries.

The actual size and value of the medical tourism market is unknown; there are in fact stunning disparities among claims.

But even conservative estimates say that hundreds of thousands of individuals are traveling to and from every continent for care every year, and that the market continues to grow.

One organization Patients Beyond Borders, which produces guidebooks for medical tourists, estimates that some seven million patients a year travel for care, making for a $20-35 billion market (not counting travel costs).

Older, sicker, and poorer patients in the US and other economies are increasingly desperate for affordable care. Dozens of countries, from Barbados to Poland to the United Arab Emirates. have launched initiatives to foster their medical tourism industries and attract patients with special visas, “health care cities,” and, as one observer put it, hospital facilities resembling “ten-star” hotels. A variety of payers, from the United Kingdom’s National Health System to self-insured employers are exploring the benefits of providing coverage for cross border care.

While it’s intriguing to consider this burgeoning market as an antidote to some of the challenges facing patients and health systems in the US and elsewhere, outsourcing health care raises certain risks that you don’t see when off shoring call centers or iPhone apps.

Most medical tourists pay out-of-pocket, providers market services directly to patients, or “consumers,” typically via the Internet; there is no insurance plan or public health system serving as a gatekeeper. That means that patients are finally in charge of their care in meaningful ways; they decide what treatments they want, and where and when they want them. But patients confronting a globe-full of treatment options don’t always have the information they need to make the right choices.

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Patients cannot confidently rely on treatment advice from the doctors and hospitals marketing their services online. As with the US fee-for-service system, medical tourism providers get paid for selling and performing services, not for improving health.

Typically, medical tourists must select clinics, hospitals and doctors a plane ride away without the benefit of a walk-through or any reliable way to compare surgical outcomes, infection rates or other important aspects of care from one facility to the next. More than 500 hospitals and clinics targeting medical tourists have pursued accreditation from organizations such as the Joint Commission International (JCI). While that “Gold Seal of Approval” signals some level of quality, accreditation measures systems, not outcomes such as successful surgeries.

So patients are left to sort through the treatment options, video testimonials and marketing claims to identify the safe and promising options. This can be a particularly daunting task when the treatment involves experimental therapies. Few areas highlight this challenge better than the market for stem cell procedures.

Hundreds of clinics are operating around the globe, offering stem cell treatments for everything from Alzheimer’s to sexual dysfunction. Patients paying tens of thousands of dollars out of pocket for stem cell therapies that they hope will fend off chronic or life threatening diseases often have to rely on their own research and the word of other patients to distinguish the legitimate therapies and clinics from those offering bogus or ineffective treatments, sometimes with tragic results.

Then there’s the risk of infection. Whether they take place across town or across the globe, all medical procedures carry the risk of acquiring infections. But some of the most popular medical tourism destinations are in low-resource areas with high rates of infectious disease.

Adding to the risk are the possibilities that medical tourists may be more vulnerable to infections as a result of their health problems, or that they may encounter unfamiliar bacteria for which they have not developed immunities.

The link between medical tourism and the spread of disease has taken on new significance with the emergence and spread of the gene that produces the multidrug resistant enzyme known as NDM-1, which shuttles easily among different bacteria. The enzyme, which arms bacteria to resist a wide range of antibiotics, was first detected in January 2008 in bacteria from a 59-year-old man undergoing treatment at a hospital in Örebro, Sweden.

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Researchers eventually tracked the enzyme to India, where the patient had been hospitalized before returning to Sweden, and named the enzyme New Delhi metallo-beta-lactamase-1 (NDM-1)—a designation that caused considerable consternation in India when the spread was linked to medical tourism. NDM-1 has since been detected in hundreds of patients in more than 40 countries. A substantial number of cases have been linked to travel to the Indian subcontinent or the Balkans, and many of those cases have involved some type of exposure to medical facilities.

Whether its infections or other surgical mishaps, when things go wrong, often the only recourse for medical tourists is to seek help in the health system they left behind in the first place. The facilitators who sell services to medical tourists on behalf of doctors and hospitals typically secure contracts that protect them from liability.

Legal options in the country where the procedure was performed are typically limited; few countries’ legal systems match the US systems’ zeal for protecting and compensating patients. Home physicians, particularly if they recommended against the procedure in the first place, may be reluctant to help when the patients return with problems. So someone who became a medical tourist to save money could end up back home with additional medical problems and limited resources to fix them.

In the end, the benefits of medical tourism—the ability to access the care we want and need, when and how we want and need it; the profits to hospitals and local domestic economies; the exchange of medical technology and expertise—may well outweigh the potential down sides.

But absent reliable figures about the volume and nature of medical travel, or any kind of meaningful global regulation of the industry, it’s impossible to accurately calculate or effectively take on these risks.

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