March 19, 2007

The New Jet Set
By Mary Anne Gates
For The Record
Vol. 19 No. 6 P. 28

The quest for affordable quality healthcare has caused a growing number of Americans to pack their bags and head for foreign soil.

The practice of medicine is going global. Whether you call it medical tourism or medical travel (the term preferred by some in the industry), more Americans are going abroad for surgery every year.

The variety of surgeries performed range from simple dental procedures and cosmetic surgery to more complex surgeries such as hip and knee replacement, heart bypass surgery, and cancer treatment with destinations as close as Costa Rica and Brazil or as far away as Singapore, India, and Thailand.

Defining Medical Tourism/Medical Travel
In the United States, medical tourism is generally defined as the practice of Americans traveling to a foreign country for surgery or other medical procedures. Although some people have been traveling overseas unnoticed for years to undergo various medical procedures, this type of travel combined with medical care is still considered a relatively new industry. It is so new, in fact, that there does not appear to be a unified consensus on what to call it.

“The term medical tourism is negative and trivializes the medical care of the patient,” says Stephanie Sulger, RN, MS, CPIC, director of international services for Medical Tours International.

Sulger is not alone in her dislike for the term. Jason Yap, MD, director of healthcare services for the Singapore Tourism Board, cites patients who travel for medical care by choice and prefers the term medical travel.

A Developing Industry
Two distinct groups of people work with patients who go overseas for surgery. One group is an evolution of the travel industry with mostly travel people (agents) getting into the business of sending Americans to remote locations for surgeries, explains Gerald Celente, publisher of the Trends Journal (www.trendsresearch.com).

Another group specializing in overseas surgery is doctors and other credentialed healthcare workers who research and visit overseas hospitals and practitioners before sending any Americans, says Celente. The medical professionals are more qualified to know which hospitals are accredited and which practitioners have the proper credentials, he says.

“From everything we are learning, most of the surgeries done overseas right now are dental and cosmetic. More Americans have overseas dental procedures done because they don’t have dental coverage,” says Celente. “It is a loosely defined, newly developing industry. We think it will evolve more into medical outsourcing. It’s going to be gigantic.”

Developing a Parallel Industry
Currently, most medical outsourcing refers to the choice some American hospitals and doctors make when they send business or IT functions overseas.

“Outsourcing allows healthcare organizations to focus on their core capabilities instead of on low-value back-office functions. It frees them to pursue their primary mission—delivering healthcare,” says Mark Voytek, global healthcare industry leader at Technology Partners International, Inc.1

Additionally, some medical tests are sent overseas to foreign doctors for interpretation. These interpretations are done for some stateside hospitals and doctors who are treating patients who have chosen to stay in the United States for their surgery. This is commonly called Knowledge Process Outsourcing (KPO) and involves making remote diagnoses, especially in teleradiology and telepathology. As more medical technicians and doctors are trained, KPO is expected to increase, especially in India, Israel, Russia, Malaysia, and China because workers are acquiring the necessary professional skills and perfecting their language skills.2

Destinations
“The big business is in dental and cosmetic surgeries. Patients are going close to home. Southern destinations are the hottest right now,” says Celente.

Costa Rica, Mexico, Argentina, and Brazil are prime locations for dental and cosmetic surgeries. More complicated surgeries are starting to take place a little farther from home in Thailand, Singapore, India, Malaysia, and South Africa, he says.

Usha C. V. Haley, PhD, director of the Global Business Center, School of Business, at the University of New Haven in Connecticut, estimates that 55,000 Americans traveled to Thailand in 2005 for a variety of operations. Medical travelers opted for everything from face-lifts and tummy tucks to hip and knee replacements and more complicated procedures such as heart bypass surgery, she says.

Overseas surgery is not unique to Americans. For example, Yap cites patients from the Middle East who go to Singapore for cancer treatment. Interestingly, cancer treatments are provided at either Singaporean facilities or by American healthcare providers such as Johns Hopkins, The West Clinic, and St. Jude’s that operate facilities in Singapore. Yap also says expatriates go to Singapore for medical care rather than use the medical services where they’re based.

Celente agrees that it’s not just Americans who travel overseas for surgery. For example, in Germany, it may take too long for some Germans to get treatment in their own country, so they go to England. Additionally, some Russians are looking for places where they can get better and cheaper treatment, he says.

Why People Travel
Yap divides the reasons people travel abroad for surgery into four categories:

• Essential healthcare: not available in their home country, or there is a long waiting list for treatment

• Affordable healthcare: available in home country but inaccessible due to high cost

• Quality healthcare: actual or perceived higher quality than in home country

• Premium healthcare: traveling to receive the best-quality treatment

Saving Money
“The primary reason to go abroad is cost,” says Haley. Many Americans who are either uninsured or underinsured save money on surgeries done overseas.

Haley says hip replacement surgery in Thailand is approximately 20% to 25% cheaper than the cost of getting the operation in the United States. The same surgery in India costs 10% to 15% of what it would cost in the United States.

Also, the cost of heart bypass surgery is approximately $56,000 stateside while the same operation will set back patients only $8,000 in Thailand and $6,000 in India, says Haley.

The savings on dental procedures can also be significant. For example, one tooth implant in the United States can cost $4,000 to $5,000. In Costa Rica, the same implant may cost only several hundred dollars, according to Celente.

Other examples include the following:

Procedure Singapore (U.S. $) United States (U.S. $)
Cataract 1,300 to 2,600 4,000
Coronary artery bypass 12,000 to 15,000 25,000
Total hip replacement 12,000 26,000
Total knee replacement 9,000 23,000

— Information provided by Wei Wei Tan, manager of healthcare services for the Singapore Tourism Board

Making the Decision to Go
While saving money is appealing to everyone, finding the right place to go for surgery requires thoroughly investigating any destination you are considering.

“It’s not only a cost factor,” says Celente. “You also want to go to places you have researched and [you] feel, ‘This is the best place for me.’”

After researching a destination hospital and checking the credentials of its staff, starting with a small operation is one way to help determine the quality of the facility and the skill of the healthcare workers, suggests Haley. “Start with something minor to get a feel for how things will go,” she says. “Don’t start with something life-threatening.”

There are several Web sites that can start patients on their journey to finding a quality hospital and skilled practitioner for nearly any surgery. They include: Medical Tours International (www.medicaltoursinternational.com), International SOS (www.internationalsos.com), and PlanetHospital (www.planethospital.com).

Offshore Care
Overseas hospitals go through many steps to make American patients comfortable. Low cost, luxury accommodations, and extended recuperation time are part of the package. Excellent patient care by well-trained nurses is also part of the attraction of overseas surgery, says Haley.

Offshore hospitals also don’t take their credentials and certifications for granted, either. They spend time reassuring patients they have all the necessary certifications to perform the procedure. And, they make sure the patient knows the doctor is well-trained and experienced, explains Haley.

If there is any doubt about the incentive foreign hospitals have to provide better-quality care, Rudy Rupak, founder and CEO of PlanetHospital, answers that question with a resounding, “Yes, they recognize that they are an ambassador of their country. They cannot afford to leave a tainted experience with anyone.”

An American Patient in Costa Rica
An injured rotator cuff complicated by soft tissue, muscle damage, and nerve damage, and further compounded by a previous injury made it difficult to find a stateside orthopedic surgeon willing to undertake the intricate surgery, says a northern Virginia real estate broker who requested anonymity for this article. This type of injury needed the skills of both an orthopedic surgeon and a neurosurgeon, he says.

After consulting with several doctors in the Virginia and Washington, D.C., area, the answer was always the same: There wasn’t anything more they could do.

Unrelenting shoulder pain prompted the uninsured, 51-year-old man to consider surgery abroad. “I had absolutely fabulous care and fabulous results,” he says. But it took several months of careful thought and serious research before he stumbled on to Medical Tours International.

“They did their homework and saved me money,” he says, estimating a U.S. operation would have cost $20,000, while he paid $4,700 for surgery in Costa Rica.

The price included all pre-op work, the surgery, post-op recovery, one night in the hospital, and a two-week stay at a recovery center. “The level of care was closer to pampering than just providing care,” he says.

However, spending less money was not the deciding factor. The Costa Rican doctor asked one critical question that got the patient’s attention. According to the patient, the doctor asked whether it was OK to consult with a neurosurgeon before tackling the surgery because such a meeting could result in a better outcome.

“Finally, someone was on the same page I was. There was a person who saw things the way I did and wanted to get it done right, not just get it done cheap,” he says.

Advantages and Disadvantages
The biggest advantage to overseas surgery is the reduced cost. The lower cost is a result of the difference in cost structure of the procedure, the medications, and other fees because the cost of living is usually lower in other countries, and all the other attendant costs are subsequently lower, explains Donald Conway, director of the healthcare initiative at the Tuck School of Business at Dartmouth College in New Hampshire.

“The treatment you get overseas is either going to be worse, as good as, or better than treatment in the United States. In many instances, it is as good or better,” says Celente.

Increasing the odds of successful treatments and surgeries with positive outcomes for the patient requires skill in matching the patient to the practitioner performing the procedure. Make sure the country is qualified to accept Americans, and the hospital meets standards of care, says Sulger. “If something happens, you have no [legal] recourse. You really have no standing,” says Conway.

Other potential pitfalls exist, too; India limits the amount of damages that can be awarded in a malpractice case. “Limiting damages is one of the reasons costs are low in India,” says Haley.

Other disadvantages can be communication issues and language barriers. “The biggest weakness in the U.S. healthcare system has always been communication about a patient from one person to another,” says Sulger.

Successful overseas communication is compounded and can be hampered by an accent that doesn’t pronounce a vowel correctly. Information missed or not correctly translated coming over the Internet can also cause problems, explains Sulger.

Additionally, allergies and medications may not translate the same way. Or a procedure such as adjusting a Lap-Band may become more complicated after a patient returns home and a doctor checks the fit of the band only to discover he or she can’t adjust it because the name of the pump or the location of the port is unknown. Thus, the procedure is unnecessarily complicated, explains Sulger.

Impact on American Hospitals
Despite an ever-increasing number of Americans going outside the country for surgeries, Celente doesn’t see it having a negative impact on how American hospitals do business.

“It’s not going to be a threat to the American medical system, but it is going to be big business,” he says.

There are some hospitals, such as Johns Hopkins, with ties to Singapore, Celente explains, but very few. Still, Celente says, “American hospitals are not globally focused. They are blindsided by the future. They don’t see it until it’s too late. This is just another form of globalization. American hospitals are off trend in so many ways. When it comes to global issues, they react.”

— Mary Anne Gates is a medical writer based in the Chicago area.

References
1. Voytek M. Healthcare Payor and Provider Organization Outsourcing Activity, The Pulse is Accelerating. November 2006, p. 5.

2. Ibid, p. 6