I am skeptical of the ability of employer wellness programs, care management, accountable care organizations or shared savings models to add meaningful value to American healthcare. I am optimistic about using consumer-facing tools to help initiate and sustain healthy behaviors, virtual health and self-service models for chronic disease management, and a combination of centers of excellence (verifying a diagnosis or treatment approach) with reference pricing (obtaining the best value for a specific treatment). Medical tourism could be an extension of reference pricing for those individuals or payers who might be willing to considers international treatment centers.
Hanefeld and Smith frame medical tourism as any consumption of health services abroad. This definition includes both wealthy private patients traveling for cheaper healthcare with a holiday as well as poor immigrants receiving care in higher income countries. They suggest that the majority of medical tourists fit neither stereotype and travel between low and middle income countries to access care that is not available in their home country. Medical tourism risks include continuity of care (sharing medical records), contracting infectious diseases (e.g., mycobacteria), and treatment failure or side effects after returning to the home country.
Today, medical tourism is focused on cosmetic surgery, dentistry, cardiovascular (e.g., coronary artery bypass surgery), orthopedic procedures, cancer, fertility, and weight-loss procedures. Advocates claim savings between 25% and 90% of what is charged in the United States. Adam Graham reports that some countries are developing reputations for proficiencies in specific procedures (e.g., Malaysia for cardiac bypass surgery, Taiwan for bone marrow transplants). Josef Woodman, CEO of Patients Beyond Borders, suggests limiting medical tourism to any procedure that costs more than $6000, acknowledging that some individuals might travel abroad to save $500. Woodman acknowledges the current out-of-pocket maximums for high-deductible health plans ($6650 for individuals and $13,300 for families) with the Affordable Care Act has dampened enthusiasm for medical tourism. As the costs of medical procedures continues to climb, more procedures could cross this threshold.
In 2013, the top 20 most expensive conditions treated in American hospitals by all payers accounted for nearly 48% of all hospital costs. Seven of these 20 conditions could be partially addressed directly by medical tourism (osteoarthritis; spondylitis, intervertebral disc disorders, other back problems; coronary atherosclerosis; cardiac dysrhythmias; heart valve disorders; fracture of neck of femur, diabetes [bariatric surgery]) and three others could be indirectly linked to medical tourism (complications of device, implant or graft; complications of surgical procedure or medical care; rehabilitation care, fitting of prostheses, and adjustment of devices). Many coverage decisions for specific interventions based on cost-effectiveness using prevailing charges in America might change based on the price reductions offered through medical tourism.
The lack of regulations managing care across national borders reduces the trust among transactions for all parties. For every promising intervention not currently available in the United States (e.g., carbon radiotherapy for some cancers), there are many more that add no value, but respond to a consumer’s sense of desperation to address a health problem (e.g., stem cell treatments for multiple sclerosis or amyotrophic lateral sclerosis). Medical tourism has prompted some to speak out against kidney transplants and surrogacy performed abroad given the high potential for coercion. To be clear, consumers have little recourse in the American legal system if they decide to travel abroad for the healthcare. From a payer’s perspective, even if the treatment episode was managed at a lower cost in another country through the member’s own dollars, any complications and follow-up care would fall under the member’s existing health insurance policy. Some insurers offer medical complications insurance that can reimburse an individual for extra costs due to post-operative complications.
In the absence of any formal regulation, consumers are left to search for independent accediting agencies to provide some reassurance about the quality of services delivered. The Joint Commission International provides certification for hospitals, ambulatory care centers, long-term care centers among other healthcare facilities. The organization stratifies the 1090 accredited facilities (as of September 1, 2019) who have achieved some type of accreditation by facility type as well as medical condition (e.g., bone marrow transplant, lumbar decompression and fixation, knee replacement). Det Norske Veritas (DNV) competes with Joint Commission International and has accredited a shorter list of facilities internationally.
Beyond the accrediation, an individual or company faciliting medical tourism would need to help travelers manage the pre-procedure evaluation, travel, and care coordination across countries. Obtaining services from countries with a public healthcare benefit package with providers earning extra income through additional cash payments would reduce the perception that tourists are “stealing” healthcare from tax-paying citizens. Countries like Australia, Canada, South Korea and Taiwan fit this model.
Medical tourism might make sense as part of a global healthcare coverage offering with consumer-facing tools to promote healthy behaviors, allow comparisons using price and quality metrics, and use participant feedback to inform others about their healthcare experience. Groups that can establish trust through face-to-face and online interactions may be more likely to encourage consumers to consider obtaining treatments in international locations. More aggressive entities may display the additional services that might be possible when including medical tourism as compared to offerings restricted to the United States.